DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Centers for Medicare & Medicaid Services 

42 CFR Parts 410, 414, 415, 421, 423, 425, 486, and 495 

[CMS-1590-P] 

RIN 0938-AR11 

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

Face-to-Face Encounters, Elimination of the Requirement for Termination of Non-Random 

Prepayment Complex Medical Review and Other Revisions to Part B for CY 2013

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

ACTION: Proposed rule. 

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

payments for Part B drugs, 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. It would also implement provisions of the Affordable Care Act by establishing a faceto-face encounter as a condition of payment for certain durable medical equipment (DME) items. 

In addition, it would implement statutory changes regarding the termination of non-random 

prepayment review under the Medicare Prescription Drug, Improvement, and Modernization Act 

of 2003. Finally, this proposed rule also includes a discussion regarding the Chiropractic 

Services Demonstration program. 

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 [OFR—insert date 60 days after the date of

filing for public inspection at OFR.]

ADDRESSES: In commenting, please refer to file code CMS-1590-P. Because of staff and 

resource limitations, we cannot accept comments by facsimile (FAX) transmission. 
CMS-1590-P 2 

 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 

http://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-1590-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-1590-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-- 
CMS-1590-P 3 

 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 stampin 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: 

Corinne Axelrod, (410) 786-5620, for any physician payment issue not identified below. 

Ryan Howe, (410) 786-3355, for issues related to practice expense methodology and 

direct practice expense inputs, telehealth services, and issues related to primary care and care 

coordination. 
CMS-1590-P 4 

Sara Vitolo, (410) 786-5714, for issues related to potentially misvalued services, 

malpractice RVUs, molecular pathology, and payment for new preventive service HCPCS Gcodes. 

Ken Marsalek, (410) 786-4502, for issues related to the multiple procedure payment 

reduction and payment for the technical component of pathology services. 

Michael Moore, (410) 786-6830, for issues related to geographic practice cost indices and 

the sustainable growth rate. 

Pam West, (410) 786-2302, for issues related to therapy services. 

Chava Sheffield, (410) 786-2298, for issues related to certified registered nurse 

anesthetists. 

Roberta Epps, (410)786-4503, for issues related to portable x-ray. 

Anne Tayloe-Hauswald, (410) 786-4546, for issues related to ambulance fee schedule 

and Part B drug payment. 

Amanda Burd, (410) 786-2074, for issues related to the DME provisions. 

Debbie Skinner, (410) 786-7480, for issues related to non-random prepayment complex 

medical review. 

Latesha Walker, (410) 786-1101, for issues related to ambulance coverage-physician 

certification statement. 

Alexandra Mugge, (410) 786-4457, for issues related to physician compare. 

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

system, incentives for e-prescribing, and Medicare shared savings program. 

Pauline Lapin, (410) 786-6883, for issues related to the chiropractic services 

demonstration budget neutrality issue. 

Gift Tee, (410) 786-9316, for issues related to the Physician Feedback Reporting 

Program and Value-Based Payment Modifier. 
CMS-1590-P 5 

Jamie Hermansen, (410) 786-2064, for issues related to Medicare coverage for hepatitis 

B vaccine. 

Andrew Morgan, (410) 786-2543, for issues related to e-prescribing under Medicare 

Part D. 

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 Website as soon as possible after they 

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

to view public comments. 

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

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

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

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

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

Table of Contents 

I. Executive Summary and Background 

II. Provisions of the Proposed Rule 

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

B. Potentially Misvalued Codes Under the Physician Fee Schedule 

C. Malpractice RVUs 

D. Geographic Practice Cost Indices (GPCIs) 

E. Medicare Telehealth Services for the Physician Fee Schedule 
CMS-1590-P 6 

F. Extension of Payment for Technical Component of Certain Physician Pathology 

Services 

G. Therapy Services 

H. Primary Care and Care Coordination 

I. Payment for Molecular Pathology Services 

J. Payment for New Preventive Services HCPCS G Codes 

K. Certified Registered Nurse Anesthetists and Chronic Pain Management Services 

L. Ordering of Portable X-Ray Services 

III. Other Provisions of the Proposed Regulation 

 A. Ambulance Fee Schedule 

 B. Part B Drug Payment: Average Sales Price (ASP) Issues 

 C. Durable Medical Equipment (DME) Face-to-Face Encounters and Written Orders 

Prior to Delivery 

 D. Elimination of the Requirement for Termination of Non-random Prepayment 

Complex Medical Review 

 E. Ambulance Coverage-Physician Certification Statement 

F. Physician Compare Website 

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

Reporting System 

H. Electronic Prescribing (eRx) Incentive Program 

I. Medicare Shared Savings Program 

J. Discussion of Budget Neutrality for the Chiropractic Services Demonstration 

K. Physician Value-Based Payment Modifier and the Physician Feedback Reporting 

Program 

L. Medicare Coverage of Hepatitis B Vaccine 
CMS-1590-P 7 

M. Updating Existing Standards for E-prescribing under Medicare Part D and Lifting the 

LTC Exemption 

IV. Technical Corrections 

 A. Waiver of Deductible for Surgical Services Furnished on the Same Date as a Planned 

Screening Colorectal Cancer Test and Colorectal Cancer Screening Test Definition 

V. Collection of Information Requirements 

VI. Response to Comments 

VII. Regulatory Impact Analysis 

Acronyms 

 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: 

AHRQ [HHS] Agency for Healthcare Research and Quality 

AMA American Medical Association 

AMA RUC AMA [Specialty Society] Relative [Value] Update Committee 

ARRA American Recovery and Reinvestment Act (Pub. L. 111-5) 

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) 

BIPA [Medicare, Medicaid, and SCHIP] Benefits Improvement Protection Act of 2000 

(Pub. L. 106-554) 

BLS Bureau of Labor Statistics 

BN Budget neutrality 

CAH Critical access hospital 

CBSA Core-Based Statistical Area 
CMS-1590-P 8 

CF Conversion factor 

CFC Conditions for Coverage 

CFR Code of Federal Regulations 

CNS Clinical nurse specialist 

CoPs Conditions of Participation 

CORF Comprehensive Outpatient Rehabilitation Facility 

CPI Consumer Price Index 

CPT [Physicians] Current Procedural Terminology (CPT codes, descriptions and other 

data only are copyright 2011 American Medical Association. All rights reserved.)

CRNA Certified registered nurse anesthetist 

CY Calendar year 

DHS Designated health services 

DME Durable medical equipment 

DMEPOS Durable medical equipment, prosthetics, orthotics, and supplies 

DOTPA Development of Outpatient Therapy Payment Alternatives 

DRA Deficit Reduction Act of 2005 (Pub. L. 109-171) 

E/M Evaluation and management 

EHR Electronic health record 

EMTALA Emergency Medical Treatment and Active Labor Act (part of the Consolidated 

Omnibus Budget Reconciliation Act of 1985 (Pub. L. 99-272) 

eRx Electronic prescribing 

FFS Fee-for-service 

FR Federal Register 

GAF Geographic adjustment factor 

GAO [U.S.] Government Accountability Office 
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GPRO Group Practice Reporting Option 

GPCI Geographic practice cost index 

HAC Hospital-acquired conditions 

HCPCS Healthcare Common Procedure Coding System 

HHA Home health agency 

HIPAA Health Insurance Portability and Accountability Act of 1996 (Pub. L. 104-191) 

HIT Health information technology 

HITECH Health Information Technology for Economic and Clinical Health Act (Title IV 

of Division B of the Recovery Act, together with Title XIII of Division A of the 

Recovery Act) 

HPSA Health Professional Shortage Area 

ICD International Classification of Diseases 

IMRT Intensity Modulated Radiation Therapy 

IOM Internet-only Manual 

IPCI Indirect practice cost index 

IPPS Inpatient prospective payment system 

IWPUT Intra-service work per unit of time 

MAC Medicare Administrative Contractor 

MCTRJCA Middle Class Tax Relief and Job Creation Act of 2012 (Pub. L. 112-96) 

MedCAC Medicare Evidence Development and Coverage Advisory Committee (formerly 

the Medicare Coverage Advisory Committee (MCAC)) 

MedPAC Medicare Payment Advisory Commission 

MEI Medicare Economic Index 

MIEA-TRHCA Medicare Improvements and Extension Act of 2006 (that is, Division B of the 

Tax Relief and Health Care Act of 2006 (TRHCA) (Pub. L. 109-432) 
CMS-1590-P 10 

MIPPA Medicare Improvements for Patients and Providers Act of 2008 (Pub. L. 110-275) 

MMA Medicare Prescription Drug, Improvement, and Modernization Act of 2003 

(Pub. L. 108-173) 

MMEA Medicare and Medicaid Extenders Act of 2010 (Pub. L. 111-309) 

MMSEA Medicare, Medicaid, and SCHIP Extension Act of 2007 (Pub. L. 110-173) 

MP Malpractice 

MPPR Multiple procedure payment reduction 

MQSA Mammography Quality Standards Act of 1992 (Pub. L. 102-539) 

NP Nurse practitioner 

NPP Nonphysician practitioner 

OACT [CMS] Office of the Actuary 

OBRA Omnibus Budget Reconciliation Act (Pub. L. 101-239) 

OIG [HHS] Office of Inspector General 

PA Physician assistant 

PC Professional component 

PE Practice expense 

PE/HR Practice expense per hour 

PERC Practice Expense Review Committee 

PFS Physician Fee Schedule 

PGP [Medicare] Physician Group Practice 

PLI Professional liability insurance 

PPS Prospective payment system 

PQRS Physician Quality Reporting System 

PRA Paperwork Reduction Act 

PPTRA Physician Payment and Therapy Relief Act of 2010 (Pub. L. 111-286 
CMS-1590-P 11 

PVBP Physician and Other Health Professional Value-Based Purchasing Workgroup 

RAC [Medicare] Recovery Audit Contractor 

RFA Regulatory Flexibility Act 

RIA Regulatory impact analysis 

RVU Relative value unit 

SBRT Stereotactic body radiation therapy 

SGR Sustainable growth rate 

TC Technical component 

TIN Tax identification number 

TPTCCA Temporary Payroll Tax Cut Continuation Act of 2011(Pub. L.112-78) 

TRHCA Tax Relief and Health Care Act of 2006 (Pub. L. 109-432) 

VBP Value-based purchasing 

Addenda Available Only Through the Internet on the CMS Website 

 In the past, the Addenda referred to throughout the preamble of our annual PFS proposed 

and final rules with comment period were included in the printed Federal Register. However, 

effective with the CY 2012 PFS proposed rule, the PFS Addenda no longer appear in the 

Federal Register. Instead these Addenda to the annual proposed and final rules with comment 

period will be available only through the Internet. The PFS Addenda along with other 

supporting documents and tables referenced in this proposed rule with comment period are 

available through the Internet on the CMS Website at http://www.cms.gov/PhysicianFeeSched/. 

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 2013 PFS 

proposed rule with comment period, refer to item CMS–1590–P. Readers who experience any 

problems accessing any of the Addenda or other documents referenced in this proposed rule with 
CMS-1590-P 12 

comment period and posted on the CMS Website identified above should contact Corinne 

Axelrod at (410) 786–5620. 

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 2011 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 2013. It also would implement 

provisions of the Affordable Care Act by establishing a face-to-face encounter as a condition of 

payment for certain durable medical equipment (DME) items. In addition, it would implement 

statutory changes regarding the termination of non-random prepayment review. 

2. Summary of the Major Provisions 

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

national uniform relative value units (RVUs) and the relative resources used in furnishing a 

service. The Act requires that national RVUs be established for physician work, practice 

expense (PE), and malpractice (MP) expense. In this major proposed rule, we propose payment 

rates for CY 2013 for the PFS, payments for Part B drugs, 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. It also proposes to implement provisions of the Affordable 
CMS-1590-P 13 

Care Act by establishing a face-to-face encounter as a condition of payment for certain durable 

medical equipment (DME) items, and by removing certain regulations regarding the termination 

of non-random prepayment review. It also proposes new claims-based data reporting 

requirements for therapy services to implement a provision in the Middle Class Tax Relief and 

Jobs Creation Act (MCTRCA). In addition, this rule proposes: 

● Potentially Misvalued Codes to be Evaluated. 

● Additional Multiple Procedure Payment Reductions (MPPR). 

● Expanding Medicare Telehealth Services. 

● Regulatory Changes regarding Payment for Technical Component of Certain Physician 

Pathology Services to Conform to Statute. 

● Primary Care and Care Coordination Service. 

● Payment rates for Newly Covered Preventive Services. 

● Definition of Anesthesia and Related Care in the Certified Registered Nurse 

Anesthetists Benefit. 

● Ordering Requirements for Portable X-ray Services. 

● Updates to the Ambulance Fee Schedule. 

● Part B Drug Payment Rates. 

● Ambulance Coverage-Physician Certification Statement. 

●Updating the-- 

++ Physician Compare Website. 

++ Physician Quality Reporting System. 

++ Electronic Prescribing (eRx) Incentive Program. 

++ Medicare Shared Savings Program. 

● Providing Budget Neutrality Discussion on the Chiropractic Demonstration. 
CMS-1590-P 14 

● Physician Value-Based Payment Modifier and the Physician Feedback Reporting 

Program. 

● Medicare Coverage of Hepatitis B Vaccine. 

● Updating Existing Standards for e-prescribing under Medicare Part D and Lifting the 

LTC Exemption. 

3. Summary of Costs and Benefits 

The statute requires that we establish by regulation each year payment amounts for all 

physicians’ service. These payment amounts are required to be adjusted to reflect the variations 

in the costs of providing services in different geographic areas. The statute also 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. 

Several proposed changes would affect the specialty distribution of Medicare 

expenditures. This proposed rule reflects the Administration’s priority on improving payment 

for primary care services. Overall, payments for primary care specialties would increase and 

payments to select other specialties would decrease due to several changes in how we propose to 

calculate payments for CY 2013. Primary care payments would increase because of a proposed 

payment for managing a beneficiary’s care when the beneficiary is discharged from an inpatient 

hospital, a SNF, an outpatient hospital observation, partial hospitalization services, or a 

community mental health center. Primary care payments also would increase due to 

redistributions from proposed reductions in payments for other specialties. Because of the 

budget-neutral nature of this system, proposed decreases in payments in one service result in 

proposed increases in payments in others. 

Payments to primary care specialties are also impacted by the completion of the 4-year 
CMS-1590-P 15 

transition to new PE RVUs using the new Physician Practice Information Survey (PPIS) data that 

was adopted in the CY 2010 PFS final rule with comment period. The projected impacts of 

using the new PPIS data are generally consistent with the impacts discussed in the CY 2012 final 

rule with comment period (76 FR 72452). 

Proposed changes in how we calculate payment when certain services are furnished 

together would result in reductions in total payments projected to cardiologists and 

ophthalmologists. Capital-intensive specialties are projected to decrease due to proposed 

changes in how the interest rate used in the PE calculation is estimated. Also, under our 

potentially misvalued codes initiative, , we propose to adjust the payment rates for two common 

radiation oncology treatment delivery methods, intensity-modulated radiation treatment (IMRT), 

and stereotactic body radiation therapy (SBRT) to reflect more realistic time projections based 

upon publicly available data. The combined effect of the PPIS transition and the latter two 

proposals would be a reduction in payments to radiation therapy centers and radiation oncology. 

B. Background

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

the Act, “Payment for Physicians' Services.” The Act requires that CMS make payments under 

the PFS using national uniform relative value units (RVUs) based on the relative resources used 

in furnishing a service. Section 1848(c) of the Act requires that national RVUs be established 

for physician work, PE, and MP expense. Before the establishment of the resource-based 

relative value system, Medicare payment for physicians’ services was based on reasonable 

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

“practitioner” is used to describe both physicians and nonphysician practitioners (such as 

physician assistants, nurse practitioners, clinical nurse specialists, certified nurse-midwives, 

psychologists, or clinical social workers) who are permitted to bill Medicare under the PFS for 

their services. 
CMS-1590-P 16 

1. Development of the Relative Value System 

a. Work RVUs 

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

Budget Reconciliation Act (OBRA) of 1989 (Pub. L. 101-239), and OBRA 1990, 

(Pub. L. 101-508). The final rule published on November 25, 1991 (56 FR 59502) set forth the 

fee schedule for payment for physicians’ services beginning January 1, 1992. Initially, only the 

physician work RVUs were resource-based, and the PE and MP RVUs were based on average 

allowable charges. 

The physician work RVUs established for the implementation of the fee schedule in 

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

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

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

(HHS). In constructing the code-specific vignettes for 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. 

Section 1848(b)(2)(B) of the Act specifies that the RVUs for anesthesia services are 

based on RVUs from a uniform relative value guide, with appropriate adjustment of the 

conversion factor (CF), in a manner to assure that fee schedule amounts for anesthesia services 

are consistent with those for other services of comparable value. We established a separate CF 

for anesthesia services, and we continue to utilize time units as a factor in determining payment 

for these services. As a result, there is a separate payment methodology for anesthesia services. 

 We establish physician work RVUs for new and revised codes based, in part, on our 

review of recommendations received from the American Medical Association/Specialty Society 

Relative Value Update Committee (AMA RUC). 

b. Practice Expense Relative Value Units (PE RVUs) 
CMS-1590-P 17 

 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 to consider 

general categories of expenses (such as office rent and wages of personnel, but excluding 

malpractice expenses) comprising PEs. 

 Section 4505(a) of the Balanced Budget Act of 1997 (BBA) (Pub. L. 105-33), amended 

section 1848(c)(2)(C)(ii) of the Act to delay 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 charge-based PE RVUs to resource-based PE RVUs. 

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

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

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

resource-based PE RVUs did not become fully effective until 2002. 

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

Clinical Practice Expert Panel (CPEP) data and the AMA’s Socioeconomic Monitoring System 

(SMS) data. The CPEP data were collected from panels of physicians, practice administrators, 

and nonphysician health professionals (for example, registered nurses (RNs)) nominated by 

physician specialty societies and other groups. The CPEP panels identified the direct inputs 

required for each physicians’ service. (We have since refined and revised these inputs based on 

recommendations from the AMA RUC.) The SMS data provided aggregate specialty-specific 

information on hours worked and PEs. 

Separate PE RVUs are established for procedures that can be furnished in both a 

nonfacility setting, such as a physician's office, and a facility setting, such as a hospital 

outpatient department (HOPD). The difference between the facility and nonfacility RVUs 

reflects the fact that a facility typically receives separate payment from Medicare for its costs of 
CMS-1590-P 18 

furnishing the service, apart from payment under the PFS. The nonfacility RVUs reflect all of 

the direct and indirect PEs of furnishing a particular service. 

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

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 in CY 2010. Direct PE RVUs were calculated for CY 2013 using this methodology, 

unless otherwise noted. 

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). For this update, we used the Physician Practice Information Survey (PPIS) 

conducted by the AMA. The PPIS is a multispecialty, nationally representative, PE survey of 

both physicians and nonphysician practitioners (NPPs) using a survey instrument and methods 

highly consistent with those of the SMS and the supplemental surveys used prior to CY 2010. 

We note that in CY 2010, for oncology, clinical laboratories, and independent diagnostic testing 

facilities (IDTFs), we continued to use the supplemental survey data to determine PE/HR values 
CMS-1590-P 19 

(74 FR 61752). Beginning in CY 2010, we provided for a 4-year transition for the new PE 

RVUs using the updated PE/HR data. In CY 2013, the final year of the transition, PE RVUs are 

calculated based on the new data. 

c. Resource-Based Malpractice RVUs 

Section 4505(f) of the BBA amended section 1848(c) of the Act requires 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 were based on malpractice 

insurance premium data collected from commercial and physician-owned insurers from all the 

States, the District of Columbia, and Puerto Rico. 

d. Refinements to the RVUs 

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

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

independently. 

The First Five-Year Review of Work RVUs was published on November 22, 1996 

(61 FR 59489) and was effective in 1997. The Second Five-Year Review of Work RVUs was 

published in the CY 2002 PFS final rule with comment period (66 FR 55246) and was effective 

in 2002. The Third Five-Year Review of Work RVUs was published in the CY 2007 PFS final 

rule with comment period (71 FR 69624) and was effective on January 1, 2007. The Fourth 

Five-Year Review of Work RVUs was published in the CY 2012 PFS final rule with comment 

period (76 FR 73026). 

Initially refinements to the direct PE inputs relied on input from the AMA RUCestablished the Practice Expense Advisory Committee (PEAC). Through March 2004, the PEAC 

provided recommendations to CMS for more than 7,600 codes (all but a few hundred of the 

codes included in the AMAs Current Procedural Terminology (CPT) codes). As part of the 
CMS-1590-P 20 

CY 2007 PFS final rule with comment period (71 FR 69624), we implemented a new bottom-up 

methodology for determining resource-based PE RVUs and transitioned the new methodology 

over a 4-year period. A comprehensive review of PE was undertaken prior to the 4-year 

transition period for the new PE methodology from the top-down to the bottom-up methodology, 

and this transition was completed in CY 2010. In CY 2010, we also incorporated the new PPIS 

data to update the specialty-specific PE/HR data used to develop PE RVUs, adopting a 4 year 

transition to PE RVUs developed using the PPIS data. 

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. 

In the CY 2005 PFS final rule with comment period (69 FR 66236), we implemented the 

first Five-Year Review of the MP RVUs (69 FR 66263). Minor modifications to the 

methodology were addressed in the CY 2006 PFS final rule with comment period 

(70 FR 70153). The second Five-Year Review and update of resource-based malpractice RVUs 

was published in the CY 2010 PFS final rule with comment period (74 FR 61758) and was 

effective in CY 2010. 

In addition to the Five-Year Reviews, beginning for CY 2009, CMS and the AMA 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 with an emphasis on the following 

categories: (1) codes and families of codes for which there has been the fastest growth; (2) codes 

or families of codes that have experienced substantial changes in PEs; (3) codes that are recently 
CMS-1590-P 21 

established for new technologies or services; (4) multiple codes that are frequently billed in 

conjunction with furnishing a single service; (5) codes with low relative values, particularly 

those that are often billed multiple times for a single treatment; (6) codes which have not been 

subject to review since the implementation of the fee schedule (the so-called 'Harvard valued 

codes'); and (7) other codes determined to be appropriate by the Secretary. 

e. Application of Budget Neutrality to Adjustments of RVUs 

 Budget neutrality (BN) typically requires that expenditures not increase or decrease as a 

result of changes or revisions to policy. However, section 1848(c)(2)(B)(ii)(II) of the Act 

requires adjustment only if the change in expenditures resulting from the annual revisions to the 

PFS exceeds a threshold amount. Specifically, adjustments in RVUs for a year may not cause 

total PFS payments to differ by more than $20 million from what they would have been if the 

adjustments were not made. In accordance with section 1848(c)(2)(B)(ii)(II) of the Act, if 

revisions to the RVUs would cause expenditures to change by more than $20 million, we make 

adjustments to ensure that expenditures do not increase or decrease by more than $20 million. 

2. Components of the Fee Schedule Payment Amounts 

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). 

The GPCIs reflect the relative costs of physician work, PE, and MP in an area compared to the 

national average costs for each component. 

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

calculated by CMS' Office of the Actuary (OACT). 

The formula for calculating the Medicare fee schedule payment amount for a given 

service and fee schedule area can be expressed as: 

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

MP)] x CF. 
CMS-1590-P 22 

3. Most Recent Changes to the Fee Schedule 

The CY 2012 PFS final rule with comment period (76 FR 73026) implemented changes 

to the PFS and other Medicare Part B payment policies. It also finalized many of the CY 2011 

interim RVUs and implemented interim RVUs for new and revised codes for CY 2012 to ensure 

that our payment systems are updated to reflect changes in medical practice and the relative 

values of services. The CY 2012 PFS final rule with comment period also addressed other 

policies including certain statutory provisions including provisions of the Affordable Care Act 

and the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008. 

In the CY 2012 PFS final rule with comment period, we announced the following for 

CY 2012: the total PFS update of -27.4 percent; the initial estimate for the sustainable growth 

rate (SGR) of -16.9 percent; and the conversion factor (CF) of $24.6712. These figures were 

calculated based on the statutory provisions in effect on November 1, 2011, when the CY 2012 

PFS final rule with comment period was issued. 

A correction notice was issued (77 FR 227) to correct several technical and typographical 

errors that occurred in the CY 2012 PFS final rule with comment period. 

On December 23, 2011, the Temporary Payroll Tax Cut Continuation Act of 2011 

(TPTCCA) (Pub. L. 112-78) was signed into law. Section 301 of the TPTCCA specified a zero 

percent update to the PFS claims from January 1, 2012 through February 29, 2012. As a result, 

the CY 2012 PFS conversion factor was revised to $34.0376 for claims with dates of service on 

or after January 1, 2012 through February 29, 2012. In addition, TPTCCA extended several 

provisions affecting Medicare services furnished on or after January 1, 2012 through February 

29, 2012, including: 

● Section 303 - the 1.0 floor on the physician work geographic practice cost index; 

● Section 304 - the exceptions process for outpatient therapy caps; 

● Section 305 - the payment to independent laboratories for the TC of physician 
CMS-1590-P 23 

pathology services furnished to certain hospital patients, and 

● Section 307 - the five percent increase in payments for mental health services. 

On February 22, 2012, the MCTRJCA was signed into law. Section 3003 extended the 

zero percent PFS update to the remainder of CY 2012. As a result of the MCTRJCA, the 

CY 2012 PFS CF was maintained as $34.0376 for claims with dates of service on or after March 

1, 2012 through December 31, 2012. In addition: 

● Section 3004 of MCTRJCA extended the 1.0 floor on the physician work geographic 

practice cost index through December 31, 2012; 

● Section 3006 continued payment to independent laboratories for the TC of physician 

pathology services furnished to certain hospital patients through June 30, 2012; and 

● Section 3005 extended the exceptions process for outpatient therapy caps through CY 

2012 and made several other changes related to therapy claims and caps. 

On March 1, 2012, as required by Section 1848(d)(1)(E) of the Act, we submitted to the 

Medicare Payment Advisory Committee (MedPAC) an estimate of the SGR and conversion 

factor applicable to Medicare payments for physicians’ services for CY 2013. The actual values 

used to compute physician payments for CY 2013 will be based on later data and are scheduled 

to be published by November 1, 2012 as part of the CY 2013 PFS final rule. 

 
CMS-1590-P 24 

II. Provisions of the Proposed Rule A. Resource-Based Practice Expense (PE) Relative Value Units (RVUs)

1. Overview 

Practice expense (PE) is the portion of the resources used in furnishing the service that reflects the general cate

physician and practitioner expenses, such as office rent and personnel wages but excluding malpractice expenses, as spsection 1848(c)(1)(B) of the Act. Section 121 of the Social Security Amendments of 1994 (Pub. L. 103-432), enacted October 31, 1994, required us to develop a methodology for a resource-based system for determining PE RVUs for eac

service. We develop PE RVUs by looking at the direct and indirect physician practice resources involved in furnishing 

Direct expense categories include clinical labor, medical supplies, and medical equipment. Indirect expenses include a

labor, office expense, and all other expenses. The sections that follow provide more detailed information about the me

translating the resources involved in furnishing each service into service-specific PE RVUs. In addition, we note that s1848(c)(2)(B)(ii)(II) of the Act provides that adjustments in RVUs for a year may not cause total PFS payments to diffthan $20 million from what they would have otherwise been if the adjustments were not made. Therefore, if revisions cause expenditures to change by more than $20 million, we make adjustments to ensure that expenditures do not increa

by more than $20 million. We refer readers to the CY 2010 PFS final rule with comment period (74 FR 61743 through 

more detailed explanation of the PE methodology. 
CMS-1590-P 25 

2. Practice Expense Methodology a. Direct Practice Expense  We use a “bottom-up” approach to determine the direct PE by adding the costs of the resources (that is, the clinand supplies) typically involved with furnishing each service. The costs of the resources are calculated using the refine

assigned to each CPT code in our PE database, which are based on our review of recommendations received from the A

detailed explanation of the bottom-up direct PE methodology, including examples, we refer readers to the Five-Year RRelative Value Units Under the PFS and Proposed Changes to the Practice Expense Methodology proposed notice (71 CY 2007 PFS final rule with comment period (71 FR 69629). b. Indirect Practice Expense per Hour Data  We use survey data on indirect PEs incurred per hour worked in developing the indirect portion of the PE RVUwe primarily used the practice expense per hour (PE/HR) by specialty that was obtained from the AMA’s SocioeconomSurveys (SMS). The AMA administered a new survey in CY 2007 and CY 2008, the Physician Practice Expense Infor

(PPIS), which was expanded (relative to the SMS) to include nonphysician practitioners (NPPs) paid under the PFS. 

 The PPIS is a multispecialty, nationally representative, PE survey of both physicians and NPPs using a consisteand methods highly consistent with those used for the SMS and the supplemental surveys. The PPIS gathered informarespondents across 51 physician specialty and healthcare professional groups. We believe the PPIS is the most compre
CMS-1590-P 26 

survey information available to date. Therefore, we used the PPIS data to update the PE/HR data for almost all of the Mspecialties that participated in the survey for the CY 2010 PFS.  When we began using the PPIS data beginning in CY 2010, we did not change the PE RVU methodology itself 

which the PE/HR data are used in that methodology. We only updated the PE/HR data based on the new survey. Furth

explained in the CY 2010 PFS final rule with comment period (74 FR 61751), because of the magnitude of payment respecialties resulting from the use of the PPIS data, we finalized a 4-year transition (75 percent old/25 percent new for C

old /50 percent new for CY 2011, 25 percent old /75 percent new for CY 2012, and 100 percent new for CY 2013) from 

RVUs to the PE RVUs developed using the new PPIS data.  Section 1848(c)(2)(H)(i) of the Act requires us to use the medical oncology supplemental survey data submitteoncology drug administration services. Therefore, the PE/HR for medical oncology, hematology, and hematology/onccontinued use of these supplemental survey data.  We do not use the PPIS data for reproductive endocrinology and spine surgery since these specialties currently 

recognized by Medicare, nor do we have a method to blend these data with Medicare-recognized specialty data. Simila

the PPIS data for sleep medicine since there is not a full year of Medicare utilization data for that specialty.  Supplemental survey data on independent labs, from the College of American Pathologists, were implemented CY 2005. Supplemental survey data from the National Coalition of Quality Diagnostic Imaging Services (NCQDIS), rindependent diagnostic testing facilities (IDTFs), were blended with supplementary survey data from the American Co
CMS-1590-P 27 

(ACR) and implemented for payments in CY 2007. Neither IDTFs nor independent labs participated in the PPIS. Theuse 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 medicindependent laboratories, and IDTFs were updated to CY 2006 using the MEI to put them on a comparable basis with t

 Previously, we have established PE/HR values for various specialties without SMS or supplemental survey data them to other similar specialties to estimate a proxy PE/HR. For specialties that were part of the PPIS for which we prcrosswalked PE/HR, we instead use the PPIS-based PE/HR. We continue previous crosswalks for specialties that did n

PPIS. However, beginning in CY 2010 we changed the PE/HR crosswalk for portable x-ray suppliers from radiology tappropriate crosswalk because these specialties are more similar to each other for physician time.  For registered dietician services, the resource-based PE RVUs have been calculated in accordance with the finacrosswalks the specialty to the “All Physicians” PE/HR data, as adopted in the CY 2010 PFS final rule with comment p

and discussed in more detail in the CY 2011 PFS final rule with comment period (75 FR 73183).  There were five specialties whose utilization data were newly incorporated into ratesetting for CY 2012. In acc

policies adopted in the CY 2012 final rule with comment period (76 FR 73036), we use proxy PE/HR values for these crosswalking values from other, similar specialties as follows: Speech Language Pathology from Physical Therapy; H

Care from All Physicians; Geriatric Psychiatry from Psychiatry; Intensive Cardiac Rehabilitation from Cardiology, and Midwife from Obstetrics/gynecology. 
CMS-1590-P 28 

 For CY 2013, there are two specialties whose utilization data will be newly incorporated into ratesetting. We a

proxy PE/HR values for these specialties by crosswalking values from other specialties that furnish similar services as Electrophysiology from Cardiology; and Sports Medicine from Family Practice. These proposed changes are reflected available on the CMS Website under the supporting data files for the CY 2013 PFS proposed rule at http://www.cms.gov/PhysicianFeeSched/. 

 As provided in the CY 2010 PFS final rule with comment period (74 FR 61751), CY 2013 is the final year of ththe PE RVUs calculated using the PPIS data. Therefore, the CY 2013 proposed PE RVUs were developed based entire

with the exceptions described in this section. c. Allocation of PE to Services 

To establish PE RVUs for specific services, it is necessary to establish the direct and indirect PE associated wit

(1) Direct Costs  The relative relationship between the direct cost portions of the PE RVUs for any two services is determined by th

relationship between the sum of the direct cost resources (that is, the clinical staff, equipment, and supplies) typically i

furnishing the services. The costs of these resources are calculated from the refined direct PE inputs in our PE databasexample, if one service has a direct cost sum of $400 from our PE database and another service has a direct cost sum odirect portion of the PE RVUs of the first service would be twice as much as the direct portion of the PE RVUs for the 

service. 
CMS-1590-P 29 

(2) Indirect Costs  Section II.A.2.b. of this proposed rule describes the current data sources for specialty-specific indirect costs used i

calculations. We allocated the indirect costs to the code level on the basis of the direct costs specifically associated wi

the greater of either the clinical labor costs or the physician work RVUs. We also incorporated the survey data describthe PE/HR discussion. The general approach to developing the indirect portion of the PE RVUs is described as follow

• 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 

determine an initial indirect allocator. For example, if the direct portion of the PE RVUs for a given service was 2.00 a

costs, on average, represented 25 percent of total costs for the specialties that furnished the service, the initial indirect awould be 6.00 since 2.00 is 25 percent of 8.00 and 6.00 is 75 percent of 8.00. 

• We then add the greater of the work RVUs or clinical labor portion of the direct portion of the PE RVUs to th

indirect allocator. In our example, if this service had work RVUs of 4.00 and the clinical labor portion of the direct PE 

1.50, we would add 6.00 plus 4.00 (since the 4.00 work RVUs are greater than the 1.50 clinical labor portion) to get an allocator of 10.00. In the absence of any further use of the survey data, the relative relationship between the indirect cothe PE RVUs for any two services would be determined by the relative relationship between these indirect cost allocatoexample, if one service had an indirect cost allocator of 10.00 and another service had an indirect cost allocator of 5.00portion of the PE RVUs of the first service would be twice as great as the indirect portion of the PE RVUs for the seco
CMS-1590-P 30 

• We next incorporate the specialty-specific indirect PE/HR data into the calculation. As a relatively extreme e

the sake of simplicity, assume in our previous example that, based on the survey data, the average indirect cost of the s

furnishing the first service with an allocator of 10.00 was half of the average indirect cost of the specialties furnishing tservice with an indirect allocator of 5.00. In this case, the indirect portion of the PE RVUs of the first service would be 

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 facility setting, we establ

RVUs: facility and nonfacility. The methodology for calculating PE RVUs is the same for both the facility and nonfacbut is applied independently to yield two separate PE RVUs. Because Medicare makes a separate payment to the facilof furnishing a service, the facility PE RVUs are generally lower than the nonfacility PE RVUs. 

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

Diagnostic services are generally comprised of two components: a professional component (PC) and a technica

(TC), each of which may be furnished independently or by different providers, or they may be furnished together as a “service. When services have PC and TC components that can be billed separately, the payment for the global componesum of the payment for the TC and PC. This is a result of using a weighted average of the ratio of indirect to direct costhe specialties that furnish the global components, TCs, and PCs; that is, we apply the same weighted average indirect 
CMS-1590-P 31 

factor to allocate indirect expenses to the global components, PCs, and TCs for a service. (The direct PE RVUs for the 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 w

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 utilizatio

procedure code at the specialty and facility/nonfacility place of service level, and the specialty-specific PE/HR data fro(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 current aggregate pool of direct PE costs. 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. 

Step 3: Calculate the aggregate pool of direct costs. This is the sum of the product of the direct costs for each 

Step 1 and the utilization data for that service. 
CMS-1590-P 32 

Step 4: Using the results of Step 2 and Step 3 calculate a direct PE scaling adjustment so that the aggregate dir

does not exceed the current aggregate direct cost pool and apply it to the direct costs from Step 1 for each service. 

Step 5: Convert the results of Step 4 to an RVU scale for each service. To do this, divide the results of Step 4 b

Note that the actual value of the CF used in this calculation does not influence the final direct cost PE RVUs, as long ais used in Step 2 and Step 5. Different CFs will result in different direct PE scaling factors, but this has no effect on thcost 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 res

for the specialties that furnish the service. Note that for services with TCs and PCs, the direct and indirect percentages service do not vary by the PC, TC, and global components. 

Step 8: Calculate the service level allocators for the indirect PEs based on the percentages calculated in Step 7. 

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 percentage * (direct PE RVUs/direct percentage) + work RVUs. 

There are two situations where this formula is modified: 
CMS-1590-P 33 

• If the service is a global service (that is, a service with global, professional, and technical components), then 

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 indire

indirect percentage (direct PE RVUs/direct percentage) + clinical PE RVUs. (Note: For global services, the indirect allocator is based on both the work RVUs and the clinical labor PE RVUs. We 

recognize that, for the PC service, indirect PEs will be allocated using the work RVUs, and for the TC service, indirect allocated using the direct PE RVUs and the clinical labor PE RVUs. This also allows the global component RVUs to eof 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 RVUs, clinical PE RVUs, or both depending on whether the service is a gl

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 

the average indirect PE percentage from the survey data. 
CMS-1590-P 34 

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

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 indir

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 specialty-specific adjusted indirect PE alloca

PFS services for a specialty by adding the product of the adjusted indirect PE allocator for each service and the utilizat

that service. 

Step 13: Using the specialty-specific indirect PE/HR data, calculate specialty-specific aggregate pools of indire

PFS services for that specialty by adding the product of the indirect PE/HR for the specialty, the physician time for the 

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

Step 14: Using the results of Step 12 and Step 13, calculate the specialty-specific indirect PE scaling factors. 

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

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. 

weighted average of the practice cost index values for the specialties that furnish the service. (Note: For services with 
CMS-1590-P 35 

we calculate the indirect practice cost index across the global components, PCs, and TCs. Under this method, the indir

cost index for a given service (for example, echocardiogram) does not vary by the PC, TC, and global component.) 

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

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 bu

neutrality (BN) adjustment. 

The final PE BN adjustment is calculated by comparing the results of Step 18 to the current pool of PE RVUs. 

adjustment is required in order to redistribute RVUs from step 18 to all PE RVUs in the PFS and because certain speci

excluded from the PE RVU calculation for ratesetting purposes, but all specialties are included for purposes of calculat

BN adjustment. (See "Specialties excluded from ratesetting calculation" later in this section.) 
CMS-1590-P 36 

(5) Setup File Information 

• Specialties excluded from ratesetting calculation: For the purposes of calculating the PE RVUs, we exclude 

specialties, such as certain nonphysician practitioners paid at a percentage of the PFS and low-volume specialties, from calculation. These specialties are included for the purposes of calculating the BN adjustment. They are displayed in T

TABLE 1: Specialties Excluded From Ratesetting Calculation 

Specialty Code Specialty Description

49 Ambulatory surgical center 50 Nurse practitioner51 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 orthotist56 Individual certified prosthestist57 Individual certified prosthetist-orthotist58 Individuals not included in 55, 56, or 57 59 Ambulance service supplier, e.g., private ambulance companies, funeral homes, etc.60 Public health or welfare agencies61 Voluntary health or charitable agencies 73 Mass immunization roster biller 74 Radiation therapy centers87 All other suppliers (e.g., drug and department stores) 88 Unknown supplier/provider specialty 89 Certified clinical nurse specialist95 Competitive Acquisition Program (CAP) Vendor 96 Optician 97 Physician assistant

A0 Hospital A1 SNF 
CMS-1590-P 37 

Specialty Code Specialty Description

A2 Intermediate care nursing facility A3 Nursing facility, other A4 HHA A5 Pharmacy A6 Medical supply company with respiratory therapist A7 Department store 

1 Supplier of oxygen and/or oxygen related equipment 2 Pedorthic personnel 3 Medical supply company with pedorthic personnel 

We are proposing to calculate the specialty mix for low volume services (fewer than 100 billed services in the p

using the same methodology we use for non-low volume services. We previously have used the survey data from the dspecialty for these low volume services. However, because these services have such low utilization, the dominant spec

change from year to year. We are proposing to calculate a specialty mix for these services rather than use the dominanorder to smooth year-to-year fluctuations in PE RVUs due to changes in the dominant specialty. 

● Crosswalk certain low volume physician specialties: Crosswalk the utilization of certain specialties with rel

PFS utilization to the associated specialties. 

• Physical therapy utilization: Crosswalk the utilization associated with all physical therapy services to the spe

physical therapy. 
CMS-1590-P 38 

• Identify professional and technical services not identified under the usual TC and 26 modifiers: Flag the serv

PC and TC services, but do not use TC and 26 modifiers (for example, electrocardiograms). This flag associates the PC 

the associated global code for use in creating the indirect PE RVUs. For example, the professional service, CPT code 9

(Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only), is associated with the global secode 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 pa

implemented in claims processing. For example, services billed with the assistant at surgery modifier are paid 16 perc

for that service; therefore, the utilization file is modified to only account for 16 percent of any service that contains the modifier. Similarly, for those services to which volume adjustments are made to account for the payment modifiers, tiapplied as well. For time adjustments to surgical services, the intraoperative portion in the physician time file is used; 

present, the intraoperative percentage from the payment files used by Medicare contractors to process Medicare claims 

Where neither is available, we use the payment adjustment ratio to adjust the time accordingly. Table 2 details the manmodifiers 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 
CMS-1590-P 39 

50 or LT and RT 

Bilateral Surgery 150% 150% of physician 

time 

51 Multiple Procedure 50% Intraoperative 

portion 

52 Reduced Services 50% 50% 53 Discontinued Procedure 50% 50% 54 Intraoperative Care only Preoperative + 

Intraoperative Percentages on the payment files used by Medicare contractors to process Medicare claims 

Preoperative + Intraoperative portion 

55 Postoperative Care only Postoperative 

Percentage on the payment files used by Medicare contractors to process Medicare claims 

Postoperative portion 

62 Co-surgeons 62.5% 50% 66 Team Surgeons 33% 33% We also make adjustments to volume and time that correspond to other payment rules, including special multiple proce

and multiple procedure payment reductions (MPPR) including the proposed ophthalmology and cardiovascular diagno

discussed in section II.B.4. of this proposed rule. We note that section 1848(c)(2)(B)(v) of the Act exempts certain red

multiple imaging procedures and multiple therapy services from the budget-neutrality calculation under section 1848(Act. These multiple procedure payment reductions are not included in the development of the relative value units. 
CMS-1590-P 40 

For anesthesia services, we do not apply adjustments to volume since the average allowed charge is used when 

RVUs and therefore includes all discounts. A time adjustment of 33 percent is made only for medical direction of two 

since that it is the only occasion where time units are duplicative. 

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

(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)))) + mainten

Where: 

minutes per year = maximum minutes per year if usage were continuous (that is, usage = 1); generally 150,000 usage = 0.5 is the standard equipment utilization assumption; 0.75 for certain expensive diagnostic imaging equ

74 FR 61753 through 61755 and section II.A.3. of the CY 2011 PFS final rule with comment period). 

price = price of the particular piece of equipment. interest rate = sliding scale (see proposal below) life of equipment = useful life of the particular piece of equipment. maintenance = factor for maintenance; 0.05. 

The interest rate we have previously used was proposed and finalized during rulemaking for CY 1998 PFS (62 FR 331CY 2012 proposed rule (76 FR 42783), we solicited comment regarding reliable data on current prevailing loan rates fo
CMS-1590-P 41 

businesses. In response to that request, the AMA RUC recommended that rather than applying the same interest rate aequipment, CMS should consider a “sliding scale” approach which varies the interest rate based on the equipment costand SBA (Small Business Administration) maximum interest rates for different categories of loan size and maturity. maximum interest rates for SBA loans are as follows: 

● Fixed rate loans of $50,000 or more must not exceed Prime plus 2.25 percent if the maturity is less than 7 ye

plus 2.75 percent if the maturity is 7 years or more. 

● For loans between $25,000 and $50,000, maximum rates must not exceed Prime plus 3.25 percent if the mat

than 7 years, and Prime plus 3.75 percent if the maturity is 7 years or more. 

● For loans of $25,000 or less, the maximum interest rate must not exceed Prime plus 4.25 percent if the matur

7 years, and Prime plus 4.75 percent, if the maturity is 7 years or more. The current Prime rate is 3.25 percent.  Based on that recommendation, for CY 2013, we are proposing to use a “sliding scale” approach based on the cmaximum interest rates for different categories of loan size (price of the equipment) and maturity (useful life of the equAdditionally, we are proposing to update this assumption through annual PFS rulemaking to account for fluctuations in 

rate and/or changes to the SBA’s formula to determine maximum allowed interest rates.  The effects of this proposal on direct equipment inputs are reflected in the CY 2013 proposed direct PE input davailable on the CMS Website under the downloads for the CY 2013 PFS proposed rule at http://www.cms.gov/Physic
CMS-1590-P 42 

Additionally, we note that the proposed PE RVUs included in Addendum B to this proposed rule reflect the RVUs that application of this proposal. 
CMS-1590-P 43 

TABLE 3: CALCULATION OF PE RVUS UNDER METHODOLOGY FOR SELECTED CODES 

Step Source Formula 

99213 

Office visit, 

est nonfacility 

33533 

CABG, 

arterial, single 

facility 

71020 

Chest x-ray 

nonfacility 

71020-TC 

Chest xray 

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 6.12 6.1

(2) Supply cost (Sup) 

Step 1 AMA 2.98 7.34 3.39 3.39 0.00 1.19 1.1

(3) Equipment cost (Eqp.) 

Step 1 AMA 0.17 0.58 7.24 7.24 0.00 0.11 0.1

(4) Direct cost (Dir) 

Step 1 =(1)+(2)+(3) 16.48 85.45 16.38 16.38 0.00 7.42 7.4

(5) Direct adjustment (Dir. Adj). 

Steps 2-4 See footnote* 0.58 0.58 0.58 0.58 0.58 0.58 0.5

(6) Adjusted Labor 

Steps 2-4 =Lab * Dir Adj =(1)*(5) 7.68 44.68 3.31 3.31 0.00 3.53 3.5

(7) Adjusted Supplies 

Steps 2-4 = Sup * Dir Adj =(2)*(5) 1.72 4.23 1.95 1.95 0.00 0.69 0.6

(8) Adjusted Equipment 

Steps 2-4 = Eqp * Dir Adj =(3)*(5) 0.10 0.34 4.17 4.17 0.00 0.06 0.0

(9) Adjusted direct 

Steps 2-4 =(6)+(7)+(8) 9.50 49.25 9.44 9.44 0.00 4.28 4.2

(10) Conversion Factor (CF) 

Step 5 PFS 34.0376 34.0376 34.0376 34.0376 34.0376 34.0376 34.037

(11) Adj. labor cost converted 

Step 5 =(Lab * Dir 

Adj)/CF 

=(6)/(10) 0.23 1.31 0.10 0.10 0.00 0.10 0.1

(12) Adj. supply cost converted 

Step 5 =(Sup * Dir 

Adj)/CF 

=(7)/(10) 0.05 0.12 0.06 0.06 0.00 0.02 0.0
CMS-1590-P 44 

Step Source Formula 

99213 

Office visit, 

est nonfacility 

33533 

CABG, 

arterial, single 

facility 

71020 

Chest x-ray 

nonfacility 

71020-TC 

Chest xray 

nonfacility 

71020-26 

Chest xray 

nonfacility 

93000 

ECG, complete 

nonfacility 

93005 

ECG, tracing 

nonfacility 

(13) Adj. equipment cost converted 

Step 5 =(Eqp * Dir 

Adj)/CF 

=(8)/(10) 0.00 0.01 0.12 0.12 0.00 0.00 0.0

(14) Adj. direct cost converted 

Step 5 =(11)+(12)+(13) 0.28 1.45 0.28 0.28 0.00 0.13 0.1

(15) Work RVU 

Setup File PFS 0.97 33.75 0.22 0.00 0.22 0.17 0.0

(16) Dir_pct Steps 6,7 Surveys 0.31 0.18 0.31 0.31 0.31 0.31 0.3(17) Ind_pct Steps 6,7 Surveys 0.69 0.82 0.69 0.69 0.69 0.69 0.6(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

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

Step 8 See (18) 0.82 6.76 0.68 0.68 0.00 0.31 0.3

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

Step 8 See Step 8 (15) (15) (15+11) (11) (15) (15+11) (11

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

Step 8 See (20) 0.97 33.75 0.32 0.10 0.22 0.27 0.1

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

Step 8 =(19)+(21) 1.79 40.51 1.00 0.78 0.22 0.59 0.4

(23) Indirect Adjustment (Ind. Adj.) 

Steps 9-11 See footnote** 0.40 0.40 0.40 0.40 0.40 0.40 0.4

(24) Adjusted indirect allocator 

Steps 9-11 =Ind Alloc * Ind 

Adj 

 0.72 16.25 0.40 0.31 0.09 0.23 0.1

(25) Ind. Practice Cost Index (IPCI) 

Steps 12-16 See Steps 12 - 

16 

 1.12 0.79 0.92 0.92 0.92 0.94 0.9

(26) Adjusted Indirect 

Step 17 = Adj.Ind Alloc 

* PCI 

=(24) * (25) 0.80 12.76 0.37 0.29 0.08 0.22 0.1
CMS-1590-P 45 

Step Source Formula 

99213 

Office visit, 

est nonfacility 

33533 

CABG, 

arterial, single 

facility 

71020 

Chest x-ray 

nonfacility 

71020-TC 

Chest xray 

nonfacility 

71020-26 

Chest xray 

nonfacility 

93000 

ECG, complete 

nonfacility 

93005 

ECG, tracing 

nonfacility 

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

Ind) * budn 

=((14)+(26)) * budn 

1.08 14.19 0.64 0.56 0.08 0.34 0.2

Note: PE RVUs in table 2, row 28, may not match Addendum B due to rounding. * The direct adj = [current pe rvus * CF * avg dir pct]/[sum [Step 2]/[Step 3]** The indirect adj = [current pe rvus * avg ind pct]/[sum of ind allocators] = [Step 9]/[Step 10] Note: The use of any particular conversion factor (CF) in Table 3 to illustrate the PE calculation has no effect on the resulting RVUs. 
CMS-1590-P 46 

3. Changes to Direct PE Inputs for Specific Services 

In this section, we discuss other specific CY 2013 proposals and changes related to direct 

PE inputs for specific services. We note that we will address comments on the interim direct PE 

inputs established in the CY 2012 PFS final rule with comment period in the CY 2013 PFS final 

rule. 

a. Equipment Minutes for Interrogation Device Evaluation Services 

It has come to our attention that the pacemaker follow-up system (EQ138) associated 

with two interrogation device management service codes does not have minutes allocated in the 

direct PE input database. Based on our analysis of these services, we believe that 10 minutes 

should be allocated to the equipment for each of the following CPT codes: 93294 (Interrogation 

device evaluation(s) (remote), up to 90 days; single, dual, or multiple lead pacemaker system 

with interim physician analysis, review(s) and report(s)), and 93295 (Interrogation device 

evaluation(s) (remote), up to 90 days; single, dual, or multiple lead implantable cardioverterdefibrillator system with interim physician analysis, review(s) and report(s)). Therefore, we are 

proposing to modify the direct PE input database to allocate 10 minutes to the pacemaker followup system for CPT codes 93294 and 93295. 

The proposed CY 2013 direct PE input database reflects these changes and is available on 

the CMS Website under the supporting data files for the CY 2013 PFS proposed rule with 

comment period at http://www.cms.gov/PhysicianFeeSched/. We also note that the proposed PE 

RVUs included in Addendum B to this proposed rule reflect the RVUs that result from 

application of this proposal. 

b. Clinical Labor for Pulmonary Rehabilitation Services (HCPCS Code G0424) 
CMS-1590-P 47 

It has come to our attention that the direct PE input database includes 15 minutes of 

clinical labor time in the nonfacility setting allocated for a CORF social worker/psychologist 

(L045C) associated with HCPCS code G0424 (Pulmonary rehabilitation, including exercise 

(includes monitoring), one hour, per session, up to two sessions per day). Based on our analysis 

of this service, we believe that these 15 minutes should be added to the 15 minutes currently 

allocated to the Respiratory Therapist (L042B) associated with this service. Therefore, we are 

proposing to modify the direct PE input database to allocate 15 additional minutes to the 

Respiratory Therapist (L042B) (for a total of 30 minutes) and delete the CORF social 

worker/psychologist (L045C) associated with HCPCS code G0424. 

The proposed CY 2013 direct PE input database reflects these changes and is available on 

the CMS Website under the supporting data files for the CY 2013 PFS proposed rule with 

comment period at http://www.cms.gov/PhysicianFeeSched/. We also note that the proposed PE 

RVUs included in Addendum B to this proposed rule reflect the RVUs that result from 

application of this proposal. 

c. Transcranial Magnetic Stimulation Services. 

For CY 2011, the CPT Editorial Panel converted Category III CPT codes 0160T and 

0161T to Category I status (CPT codes 90867 (Therapeutic repetitive transcranial magnetic 

stimulation (TMS) treatment; initial, including cortical mapping, motor threshold determination, 

delivery and management), and 90868 (Therapeutic repetitive transcranial magnetic stimulation 

(TMS) treatment; subsequent delivery and management, per session)), which were contractor 

priced on the PFS. For CY 2012, the CPT Editorial Panel modified CPT codes 90867 and 

90868, and created CPT code 90869 ((Therapeutic repetitive transcranial magnetic stimulation 

(TMS) treatment; subsequent motor threshold re-determination with delivery and management.) 
CMS-1590-P 48 

In the CY 2012 PFS final rule with comment period, we established interim final values based on 

refinement of RUC recommended work RVUs, direct PE inputs, and malpractice risk factor 

crosswalks for these services (76 FR 73201). 

Subsequent to the development of interim final PE RVUs, it came to our attention that the 

application of our usual PE methodology resulted in anomalous PE values for these services. As 

we explain in section II.A.2.c.2 of this proposed rule with comment period, for a given service, 

we use the direct costs associated with a service (clinical staff, equipment, and supplies) 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. 

For services almost exclusively furnished by one specialty, the average percentage of 

indirect costs relative to direct costs would ordinarily be used to determine the initial indirect 

allocator. For specialties that typically incur significant direct costs relative to indirect costs, the 

initial indirect allocator for their services is generally lower than for the specialties that typically 

incur lower direct costs relative to indirect costs. Relative to direct costs, the methodology 

generally allocates a greater proportion of indirect PE to services furnished by psychiatrists, for 

example, than to services furnished by specialties that typically incur significant direct costs, 

such as radiation oncologists. In the case of the TMS, however, the direct costs incurred by 

psychiatrists reporting the codes far exceed the direct costs typical to any other service 

predominantly furnished by psychiatrists. This drastic difference in the direct costs of TMS 

relative to most other services furnished by psychiatrists results in anomalous PE values since 

code-level indirect PE allocation relies on typical resource costs for the specialties that furnish 

the service. In other words, the amount of indirect PE allocated to TMS services is based on the 

proportion of indirect expense to direct expense that is typical of other psychiatric services, and 
CMS-1590-P 49 

is not on par with other services that require similar investments in capital equipment and highcost, disposable supplies. 

Historically, we have contractor-priced services with resource costs that cannot be 

appropriately valued within the generally applicable PE methodology used to price services 

across the PFS. Because there is no mechanism to develop appropriate payment rates for these 

services within our current methodology, we are proposing to contractor price these codes for 

CY 2013. 

d. Spinal Cord Stimulation Trial Procedures in the Nonfacility Setting 

Stakeholders have recently brought to our attention that CPT code 63650 (Percutaneous 

implantation of neurostimulator electrode array, epidural) is frequently furnished in the physician 

office setting but is not priced in that setting. We note that the valuation of a service under the 

PFS in particular settings does not address whether those services are medically reasonable and 

necessary in the case of individual patients, including being furnished in a setting appropriate to 

the patient’s medical needs and condition. However, because these services are being furnished 

in the nonfacility setting, we believe that CPT code 63650 should be reviewed to establish 

appropriate nonfacility inputs. We propose to review CPT code 63650 and request 

recommendations from the AMA RUC and other public commenters on the appropriate 

physician work RVUs (as measured by time and intensity), and facility and nonfacility direct PE 

inputs for this service. We understand that disposable leads comprise a significant resource cost 

for this service and are currently separately reportable to Medicare for payment purposes when 

the service is furnished in the physician office setting. Disposable medical supplies are not 

considered prosthetic devices paid under the Durable Medical Equipment, Prosthetic/Orthotic, 

and Supplies (DMEPOS) fee schedule and generally are incorporated as nonfacility direct PE 
CMS-1590-P 50 

inputs to PE RVUs. We seek comment on establishing nonfacililty PE RVUs for CPT code 

63650. 
CMS-1590-P 51 

B. Potentially Misvalued Codes Under the Physician Fee Schedule

1. Valuing Services Under the PFS 

To value 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; practice 

expense (PE); and malpractice. 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 physician 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.” 

As discussed in detail in sections I.B.1.b. and I.B.1.c. of this proposed rule, the statute 

also defines the PE and malpractice components and provides specific guidance in the 

calculation of the RVUs for each of these components. 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)(1)(C) of the Act defines 

the malpractice component as “the portion of the resources used in furnishing the service that 

reflects malpractice expenses in furnishing the service.” Sections 1848 (c)(2)(C)(ii) and (iii) of 

the Act specify that PE and malpractice expense RVUs shall be determined based on the relative 

PE/malpractice expense resources involved in furnishing the service. 

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. On March 23, 2010, the 

Affordable Care Act was enacted, further requiring the Secretary to periodically identify and 
CMS-1590-P 52 

review potentially misvalued codes and make appropriate adjustments to the relative values of 

those services identified as being potentially misvalued. Section 3134(a) of the Affordable Care 

Act added a new section 1848(c)(2)(K) to the Act, which 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 3134(a) of the Affordable Care Act 

also added a new section 1848(c)(2)(L) to the Act which requires the Secretary to develop a 

process to validate the RVUs of certain potentially misvalued codes under the PFS, identified 

using the same criteria used to identify potentially misvalued codes, and to make appropriate 

adjustments. 

As discussed in section I.B.1.a. of this proposed rule, each year we develop and propose 

appropriate adjustments to the RVUs, taking into account the recommendations provided by the 

American Medical Association Specialty Society Relative Value Scale Update Committee 

(AMA RUC), the Medicare Payment Advisory Commission (MedPAC), and others. For many 

years, the AMA RUC has provided us with recommendations on the appropriate relative values 

for new, revised, and potentially misvalued PFS services. We review these recommendations on 

a code-by-code basis and consider these recommendations in conjunction with analyses of data 

sources, such as claims data, to inform the decision-making process as authorized by the law. 

We may also consider analyses of physician 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 AMA RUC. We conduct a clinical review to assess the appropriate RVUs 
CMS-1590-P 53 

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 appropriate adjustments to the RVUs, explain the basis 

of these adjustments, and respond to public comments in the PFS proposed and final rules. 

2. Identifying, Reviewing, and Validating the RVUs of Potentially Misvalued Services on the 

PFS 

a. Background 

In its March 2006 Report to the Congress, MedPAC noted 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 for a number of reasons: 

For example, 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.'' That is, the amount of physician work needed to furnish an existing service may 

decrease as physicians build experience furnishing that service. Services can also become 

overvalued when PEs decline. 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 PEs 

rise. In the ensuing years since MedPAC's 2006 report, additional groups of potentially 
CMS-1590-P 54 

misvalued services have been identified by the Congress, CMS, MedPAC, the AMA RUC, and 

other stakeholders. 

In recent years, CMS and the AMA RUC have taken increasingly significant steps to 

address potentially misvalued codes. As MedPAC noted in its March 2009 Report to Congress, 

in the intervening years since MedPAC made the initial recommendations, “CMS and the AMA 

RUC have taken several steps to improve the review process.'' Most recently, section 

1848(c)(2)(K)(ii) of the Act (as added by section 3134(a) of the Affordable Care Act) directed 

the Secretary to specifically examine, as determined appropriate, potentially misvalued services 

in seven categories as follows: 

● 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 PFS (the 

so-called `Harvard-valued codes'); and 

● Other codes determined to be appropriate by the Secretary. 

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 
CMS-1590-P 55 

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. Finally, 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) which may include consolidation of individual 

services into bundled codes for payment under the PFS. 

In addition to these requirements, section 3003 (b)(1) of the Middle Class Tax Cut and 

Job Creation Act of 2012 (Pub. L. 112-96), requires that the Secretary conduct a study that 

examines options for bundled or episode-based payment to cover physicians’ services currently 

paid under the PFS under section 1848 of the Act for one or more prevalent chronic conditions or 

episodes of care for one or more major procedures. In conducting the study, the Secretary shall 

consult with medical professional societies and other relevant stakeholders. Additionally, the 

study shall include an examination of related private payer payment initiatives. This section also 

requires that not later than January 1, 2013, the Secretary submit to certain committees of the 

Congress a report on the study. The report shall include recommendations on suitable alternative 

payment options for services paid under the PFS and on associated implementation requirements. 

Bundling is one method for structuring payment that can improve payment accuracy and 

efficiency, assuming the bundling proposal has considered the payment system, context, and 

included services. Current work on bundling to date has targeted specific codes and sets of 

codes. Specifically, our ongoing work identifying, reviewing, and validating the RVUs of 
CMS-1590-P 56 

potentially misvalued services on the PFS will support the development of this report. As 

detailed above, through the potentially misvalued codes initiative we are currently identifying for 

review codes that are frequently billed together and codes with low relative values billed in 

multiples. Many of the codes identified through these screens have been referred to the CPT 

Editorial Panel for the development of a comprehensive or bundled code, and several bundled 

codes have already been created and valued. Additionally, in section II.B.2.d. of this CY 2013 

PFS proposed rule, we discuss improving the value of the global surgical package and request 

public comment on methods of obtaining accurate and current data on E/M services furnished as 

part of global surgical procedures. This information on measuring post-operative work in our 

current payment bundles also will inform our report to the Congress. We will continue to 

examine options for bundled or episode-based payments and will include our recommendations 

and implementation options in our report to the Congress submitted no later than January 1, 

2013. 

b. Progress in Identifying and Reviewing Potentially Misvalued Codes 

In accordance with our statutory mandate, we have identified and reviewed numerous 

potentially misvalued codes in all seven of the categories 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. In the current process, we identify potentially misvalued codes 

for review, and request recommendations from the AMA RUC and other public commenters on 

revised work RVUs and direct PE inputs for those codes. The AMA RUC, through its own 

processes, identifies potentially misvalued codes for review, and through our public nomination 

process for potentially misvalued codes established in the CY 2012 PFS final rule, other 
CMS-1590-P 57 

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 Five-Year 

Review process, we have reviewed over 1,000 potentially misvalued codes to refine work RVUs 

and direct PE inputs. We have adopted appropriate work RVUs and direct PE inputs for these 

services as a result of these reviews. 

Our prior reviews of codes under the potentially misvalued codes initiative have included 

codes in all seven categories specified in section 1848(c)(2)(K)(ii) of the Act, listed above. 

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 last year’s PFS proposed rule (CY 2012), we identified potentially misvalued codes in 

the category of “Other codes determined to be appropriate by the Secretary,'' referring a list of 

the highest PFS expenditure services, by specialty, that had not been recently reviewed (76 FR 

73059 through73068). In the CY 2012 final rule with comment period we finalized 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 public nomination of potentially misvalued services to 

replace the Five-Year review process (76 FR 73058 through 73059). Below we discuss 

proposals that support our continuing efforts to appropriately identify, review, and adjust values 

for potentially misvalued codes. 

c. Validating RVUs of Potentially Misvalued Codes 

In addition to identifying and reviewing potentially misvalued codes, section 3134(a) of 

the Affordable Care Act added section 1848(c)(2)(L) of the Act, which specifies that the 

Secretary shall establish a formal process to validate RVUs under the PFS. The validation 
CMS-1590-P 58 

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 seven categories of potentially misvalued codes specified by 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). In CY 

2012 we intend to enter into a contract to assist us in validating RVUs of potentially misvalued 

codes that will explore a model for the validation of physician work under the PFS, both for new 

and existing services. We plan to discuss this model further in future rulemaking. 

d. Improving the Valuation of the Global Surgical Package 

(1) Background 

We applied the concept of payment for a global surgical package under the PFS at its 

inception on January 1, 1992 (56 FR 59502). For each global surgical procedure, we establish a 

single payment, which includes payment for a package of all related services typically furnished 

by the surgeon furnishing the procedure during the global period. Each global surgery is paid on 
CMS-1590-P 59 

the PFS as a single global surgical package. Each global surgical package payment rate is based 

on the work necessary for the typical surgery and related pre- and post-operative work. The 

global period may include 0, 10, or 90 days of post-operative care, depending on the procedure. 

For major procedures, those with a 90-day global period, the global surgical package payment 

also includes the day prior to the day of surgery. 

Some global surgical packages have been valued by adding the RVU of the surgical 

procedure and all pre- and post-operative evaluation and management (E/M) services included in 

the global period. Others have been valued using magnitude estimation, in which case, the 

overall RVU for the surgical package was determined without factoring in the specific RVUs 

associated with the E/M services in the global period. The number and level of E/M services 

identified with a global surgery payment are based on the typical case. Even though a surgical 

package may have been developed with several E/M services included, a physician is not 

required to furnish each pre- or post-operative visit to bill for the global surgical package. 

Similar to other bundled services on the PFS, when a global surgery code is billed, the 

bundled pre- and post-operative care is not separately payable; surgeons or other physician 

billing a surgical procedure, cannot separately bill for the E/M services that are included in the 

global surgical package. 

(2) Measuring Post-Operative Work 

The use of different methodologies for valuing global surgical packages since 1992 has 

created payment rates with a wide range of E/M services included within the post-operative 

period. This is especially true among those with 90-day global periods. More recently reviewed 

codes tend to have fewer E/M services in the global period, and the work RVUs of those E/M 

services are often accounted for in the value for the global surgical package. The value of less 
CMS-1590-P 60 

recently reviewed global surgeries frequently do not appear to include the full work RVUs of 

each E/M service in the global surgical package, and the numbers of E/M services included in 

the post-operative period can be inconsistent within a family of procedures. For example, there 

is significant variation in the number and level of E/M services included in two transplantation 

procedures in Table 4. Pre-, intra-, and post-operative times, including the number of postoperative visits, for each global surgical package can be found in the physician time file on the 

CMS Website at 

http://www.cms.gov/PhysicianFeeSched/PFSFRN/itemdetail.asp?filterType=none&filterByDID

=-99&sortByDID=4&sortOrder=descending&itemID=CMS1253669&intNumPerPage=10. 

TABLE 4: Transplantation Procedures Showing a Significant Range in the Number 

of Included E/M Services 

E/M services included in global 

CPT period 

Code Short Descriptor 

Work 

RVU 99213 99231 99238 99291 

Total E/M 

Work 

RVU 

50360 Transplantation of 

kidney 

40.90 9 12 1 10 64.13 

47135 Transplantation of liver 83.64 7 0 0 0 6.79 

 

In 2005, the HHS Office of Inspector General (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 in the surgeons’ medical 

records to establish whether the surgeon furnished post-operative E/M services. The OIG 

findings show that surgeons typically furnished fewer E/M services in the post-operative period 

than were identified with the global surgical package payment for each procedure. A smaller 

percentage of surgeons furnished more E/M services than were identified with the global surgical 

package payment. The OIG could only review the number of face-to-face services and was not 
CMS-1590-P 61 

able to review the level of E/M services that the surgeons furnished due to a lack of 

documentation in surgeons’ medical records. The OIG concluded that the RVUs for the global 

surgical package are too high because they include the work of E/M services that are not 

typically furnished within the global period for the reviewed procedures. 

Following the 2005 report, the OIG continued to investigate E/M services furnished 

during the global surgical period. In May 2012, the OIG published a report titled 

“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 identified as part of the global period for that 

service. Once again, a smaller percentage of surgeons furnished more E/M services than were 

identified with the global surgical package payment. The OIG concluded that the RVUs for the 

global surgical package are too high because they include the work of E/M services that are not 

typically 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 global surgical payments to reflect the number of E/M services that are 

actually being furnished. Under the PFS, we do not ask surgeons to report bundled services on 

their claim when billing for the global surgical package as we do providers furnishing bundled 

services under other Medicare payment systems. Since it is not necessary for a surgeon to 

identify the level and code of the E/M services actually furnished during the global period, there 

is very limited documentation on the frequency or level of post-operative services. Without 

sufficient documentation, a review of the medical record cannot accurately determine the number 

or level of E/M services furnished in the post-operative period. 
CMS-1590-P 62 

As noted above, section 1848(c)(2)(K) of the Act (as added by section 3134 of the 

Affordable Care Act), which essentially codified the potentially misvalued codes initiative, 

requires that the Secretary identify and review potentially misvalued services with an emphasis 

on several categories, and recognizes the Secretary’s discretion to identify additional potentially 

misvalued codes. Several of the categories of potentially misvalued codes support better 

valuation of global surgical package codes. We have made efforts to prioritize the review of 

RVUs for services on the PFS that have not been reviewed recently or for services where there is 

a potential for misuse. One of the priority categories for review of potentially misvalued codes is 

services that have not been subject to review since the implementation of the PFS (the so-called 

“Harvard-valued codes”). In the CY 2009 PFS proposed rule, we requested that the AMA RUC 

engage in an ongoing effort to review the remaining Harvard-valued codes, focusing first on the 

high-volume, low intensity codes (73 FR 38589). For the Fourth Five-Year Review (76 FR 

32410), we requested that the AMA RUC review services that have not been reviewed since the 

original implementation of the PFS with utilization greater than 30,000 (Harvard-valued—

Utilization > 30,000). In section II.B.3 of this proposed rule, we propose to review Harvardvalued services with annual allowed charges that total at least $10,000,000 (Harvard-valued—

Allowed charges ≥$10,000,000), and request recommendations from the AMA RUC and other 

public commenters on appropriate values for these services. 

Of the more than 1,000 identified potentially misvalued codes, just over 650 are surgical 

services with a global period of 0, 10, or 90 days. We have completed our review of 450 of these 

potentially misvalued surgical codes. These efforts are important, but we believe the usual 

review process does not go far enough to assess whether the valuation of global surgical 

packages reflects the number and level of post-operative services that are typically furnished. To 
CMS-1590-P 63 

support our statutory obligation to identify and review potentially misvalued services and to 

respond to the OIG’s concern that global surgical package payments are misvalued, we believe 

that we should begin gathering more information on the E/M services that are typically furnished 

with surgical procedures. Information regarding the typical work involved in surgical 

procedures with a global period is necessary to evaluate whether certain surgical procedures are 

appropriately valued. While the AMA RUC reviews and recommends RVUs for services on the 

PFS, we complete our own assessment of those recommendations, and may adopt different 

RVUs. However, for procedures with a global period, the lack of claims data and documentation 

restrict our ability to review and assess the appropriateness of their RVUs. 

We are seeking comments on methods of obtaining accurate and current data on E/M 

services furnished as part of a global surgical package. We are especially interested in and invite 

comments on a claims-based data collection approach that would include reporting E/M services 

furnished as part of a global surgical package, as well as other valid, reliable, generalizable, and 

robust data to help us identify the number and level of E/M services typically furnished in the 

global surgical period for specific procedures. We will carefully weigh all comments received as 

we consider ways to appropriately review values for global surgical packages. 

3. CY 2013 Identification and Review of Potentially Misvalued Services 

a. Public Nomination of Potentially Misvalued Codes 

In the CY 2012 PFS final rule, we finalized a public nomination process for potentially 

misvalued codes (76 FR 73058). Under the previous Five-Year Reviews, the public nominated 

potentially misvalued codes for review. To allow for public input and to preserve the public’s 

ability to identify and nominate potentially misvalued codes for review under our annual 

potentially misvalued codes initiative, we established a process by which the public can submit 
CMS-1590-P 64 

codes, along with documentation supporting the need for review, on an annual basis. 

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 physician time. 

● An anomalous relationship between the code being proposed for review and other 

codes. 

● Evidence that technology has changed physician work, that is, diffusion of technology. 

● Analysis of other data on time and effort measures, such as operating room logs or 

national and other representative databases. 

● Evidence that incorrect assumptions were made in the previous valuation of the 

service, such as a misleading vignette, survey, or flawed crosswalk assumptions in a previous 

evaluation. 

● Prices for certain high cost supplies or other direct PE inputs that are used to determine 

PE RVUs are inaccurate and do not reflect current information. 

● Analyses of physician 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), and the Physician Quality 

Reporting System (PQRS) databases). 
CMS-1590-P 65 

● National surveys of physician time and intensity from professional and management 

societies and organizations, such as hospital associations. 

Under this newly established process, after we receive the nominated codes during the 

60-day comment period following the release of the annual PFS final rule with comment period, 

we would evaluate the supporting documentation and assess whether they appear to be 

potentially misvalued codes appropriate for review under the annual process. In the following 

year’s PFS proposed rule, we would publish the list of nominated codes, and indicate whether 

each nominated code will be reviewed as potentially misvalued. 

This year is the first year we are considering codes we received through this public 

nomination process for potentially misvalued codes. In the 60 days following the release of the 

CY 2012 PFS final rule with comment period, we received nominations and supporting 

documentation for review of the codes listed in Tables 5 and 6. A total of 36 CPT codes were 

nominated. The majority of the nominated codes were codes for which we finalized RVUs in the 

CY 2012 PFS final rule. That is, the RVUs were interim in CY 2011 and finalized for CY 2012, 

or proposed in either the Fourth Five-Year Review of Work or the CY 2012 PFS proposed rule 

and finalized for CY 2012. Under this annual public nomination process, we note that it would 

be highly unlikely that we would determine that a nominated code is appropriate for review 

under the potentially misvalued codes initiative if it had been reviewed in the years immediately 

preceding its nomination since we believe that the best information on the level of physician 

work and PE inputs already would have been available through that recent review. Nonetheless, 

we evaluated the supporting documentation for each nominated code to ascertain whether the 

submitted information demonstrated that the code is potentially misvalued. 

TABLE 5: CPT Codes Nominated as Potentially Misvalued in CY 2012 Final Rule 

Comment Period: Proposed Action 
CMS-1590-P 66 

CPT 

Code Short Descriptor 

Last 

Reviewed 

For: CMS Proposed Action 

Regulations.gov

comment search 

33282 Implant pat-active ht record CY 2000 

Review and add nonfacility inputs. 

Not considered potentially 

misvalued. 

CMS-2011-0131-1422 

33284 Remove pat-active ht record CY 2000 

Review and add nonfacility inputs. 

Not considered potentially 

misvalued. 

CMS-2011-0131-1422 

77336 Radiation physics consult 

CY 2003 

(PE Only) 

Review as a potentially misvalued 

code. 

CMS-2011-0131-1617 

94762 Measure blood oxygen level 

CY 2010 

(PE Only) 

Propose revisions in the CY 2013 

PFS proposed rule. 

CMS-2011-0131-

1615; CMS-2011-

0131-1412; CMS2011-0131-1632 

CPT codes 33282 (Implantation of patient-activated cardiac event recorder) and 33284 

(Removal of an implantable, patient-activated cardiac event recorder) were nominated for review 

as potentially misvalued codes. The commenter asserted that CPT codes 33282 and 33284 are 

misvalued in the nonfacility setting because these CPT codes currently are only priced in the 

facility setting even though physicians perform these services in the office setting. The 

commenter requested that we establish appropriate payment for the services when furnished in a 

physician office. Specifically, they requested that CMS establish nonfacility PE RVUs for these 

services. We do not consider the lack of pricing in a particular setting as an indicator of a 

potentially misvalued code. However, given that these services are now furnished in the 

nonfacility setting, we believe that CPT codes 33282 and 33284 should be reviewed to establish 

appropriate nonfacility inputs. We note, as did the commenter, that the valuation of a service 

under the PFS in a particular setting does not address whether those services and the setting in 

which they are furnished are medically reasonable and necessary for a patient’s medical needs 

and condition. We propose to review CPT codes 33282 and 33284 and request 

recommendations from the AMA RUC and other public commenters on the appropriate 
CMS-1590-P 67 

physician work RVUs (as measured by time and intensity), and facility and nonfacility direct PE 

inputs for these services. 

Like CPT codes 33282 and 33284, stakeholders have requested that we establish 

appropriate payment for CPT code 63650 (Percutaneous implantation of neurostimulator 

electrode array, epidural) when furnished in an office setting. This request was not submitted as 

a potentially misvalued code nomination. However, given that these services are now furnished 

in the nonfacility setting, we believe CPT code 63650 should be reviewed to establish 

appropriate nonfacility inputs. Please see section II.A.3 (Changes to Direct Inputs for Specific 

Services) for a discussion of spinal code stimulation trial procedures in the nonfacility setting. 

CPT code 77336 (Continuing medical physics consultation, including assessment of 

treatment parameters, quality assurance of dose delivery, and review of patient treatment 

documentation in support of the radiation oncologist, reported per week of therapy) was 

nominated for review as a potentially misvalued code. The commenter asserted that CPT code 

77336 is misvalued because changes in the technique for rendering continuing medical physics 

consultations have resulted in changes to the knowledge required, time, and effort expended, and 

complexity of technology associated with the tasks performed by the physicist other staff. 

Additionally the commenter believes that the direct PE inputs no longer accurately reflect the 

resources used to deliver this service and may be undervalued. CPT code 77336 was last 

reviewed for CY 2003. After evaluating the detailed supporting information that the commenter 

provided, we believe there may have been changes in technology and other PE inputs since we 

last reviewed the service, and that further review is warranted. As such, we propose to review 

CPT code 77336 as potentially misvalued and request recommendations from the AMA RUC 
CMS-1590-P 68 

and other public commenters on the direct PE inputs for this service, and physician work RVUs 

and direct PE inputs for the other services within this family of CPT codes. 

CPT code 94762 (Noninvasive ear or pulse oximetry for oxygen saturation; by 

continuous overnight monitoring (separate procedure)) was nominated for review as a potentially 

misvalued code. Commenters asserted that CPT code 94762 is misvalued because the time 

currently allocated to the various direct PE inputs does not accurately reflect current practice. 

Commenters also asserted that independent diagnostic testing facilities are not appropriately 

accounted for in the current indirect PE methodology. In response to these stakeholder concerns, 

we reviewed the PE inputs for CPT code 94762, which was last reviewed for CY 2010. We 

believe CPT code 94762 is misvalued, and we are proposing changes to the PE inputs for CY 

2013. Following clinical review, we believe that the current time allocated to clinical labor and 

supplies appropriately reflects current practice. However, we believe that 480 minutes (8 hours) 

of equipment time for the pulse oximetry recording slot and pulse oximeter with printer are more 

appropriate for this overnight monitoring procedure code. As such, we are proposing this 

refinement to the direct PE inputs for CPT code 94762 for CY 2013. These proposed 

adjustments are reflected in the CY 2013 proposed direct PE input database, available on the 

CMS Website under the downloads for the CY 2013 PFS proposed rule at 

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

CPT code 53445 (Insertion of inflatable urethral/bladder neck sphincter, including 

placement of pump, reservoir, and cuff) was nominated for review as a potentially misvalued 

code. CPT code 53445 was identified through the site-of-service anomaly potentially misvalued 

code screen for CY 2008 and is currently interim for CY 2012 and open to public comment. We 

will consider the content of the potentially misvalued code nomination and supporting 
CMS-1590-P 69 

documentation for CPT code 53445 as comments on the interim final value, and will address the 

comments in the CY 2013 PFS final rule with comment period when we address the final value 

of the CPT code. 

For purposes of CY 2013 rulemaking, we do not consider the other nominated codes, 

listed in Table 6 to be potentially misvalued because these codes were last reviewed and valued 

for CY 2012 and the supporting documentation did not provide sufficient evidence to 

demonstrate that the codes should be reviewed as potentially misvalued for CY 2013 or CY 

2014. The supporting documentation for these services generally mirrored the public comments 

previously submitted, to which CMS has already responded. 

TABLE 6: CPT Codes Nominated as Potentially Misvalued in CY 2012 Final Rule 

Comment Period: No Further Action Proposed 

CPT 

Code Short Descriptor 

28820 Amputation of toe 

28825 Partial amputation of toe 

35188 Repair blood vessel lesion 

35612 Artery bypass graft 

35800 Explore neck vessels 

35840 Explore abdominal vessels 

35860 Explore limb vessels 

36819 Av fuse uppr arm basilic 

36825 Artery-vein autograft 

43283 Lap esoph lengthening 

43327 Esoph fundoplasty lap 

43328 Esoph fundoplasty thor 

43332 Transab esoph hiat hern rpr 

43333 Transab esoph hiat hern rpr 

43334 Transthor diaphrag hern rpr 

43335 Transthor diaphrag hern rpr 

43336 Thorabd diaphr hern repair 

43337 Thorabd diaphr hern repair 

43338 Esoph lengthening 

47563 Laparo cholecystectomy/graph 

49507 Prp i/hern init block >5 yr 

49521 Rerepair ing hernia blocked 
CMS-1590-P 70 

CPT 

Code Short Descriptor 

49587 Rpr umbil hern block > 5 yr 

49652 Lap vent/abd hernia repair 

49653 Lap vent/abd hern proc comp 

49654 Lap inc hernia repair 

49655 Lap inc hern repair comp 

53445* Insert uro/ves nck sphincter 

60220 Partial removal of thyroid 

60240 Removal of thyroid 

60500 Explore parathyroid glands 

95800 Slp stdy unattended 

*CPT code 53445 is currently interim and open for public 

comment. We are accepting as public comment the 

nomination information submitted and will address these 

comments in the CY 2013 PFS final rule with comment 

period. 

b. Potentially Misvalued Code Lists 

As mentioned above, in the last several annual PFS proposed rules we have identified 

lists of potentially misvalued codes for review. We believe it is imperative that we continue to 

identify new lists of potentially misvalued codes for review to appropriately identify, review, and 

adjust values for potentially misvalued codes for CY 2013. 

(1) Review of Harvard-Valued Services with Medicare Allowed Charges of $10,000,000 or 

More 

For many years, we have been reviewing ‘Harvard-valued’ CPT codes through the 

potentially misvalued code initiative. The RVUs for Harvard-valued CPT codes have not been 

reviewed since they were originally valued in the early 1990s at the beginning of the PFS. While 

the principles underlying the relative value scale have not changed, over time the methodologies 

we use for valuing services on the PFS have changed, potentially disrupting the relativity 

between the remaining Harvard-valued codes and other codes on the PFS. At this time, nearly 

all CPT codes that were Harvard-valued and had Medicare utilization of over 30,000 allowed 
CMS-1590-P 71 

services per year have been reviewed. Moving forward, we propose to review Harvard-valued 

services with Medicare allowed charges of $10 million or greater per year. The CPT codes 

meeting these criteria have relatively low Medicare utilization (as we have reviewed the services 

with utilization over 30,000), but account for significant Medicare spending annually and have 

never been reviewed. We recognize that several of the CPT codes meeting these criteria have 

already been identified as potentially misvalued through other screens and may currently be 

scheduled for review for CY 2013. We also recognize that other codes meeting these criteria 

have been referred by the AMA RUC to the CPT Editorial Panel. In these cases, we are not 

proposing re-review of these already identified services, but for the sake of completeness, we 

include them as a part of this category of potentially misvalued services. We recognize that the 

relatively low Medicare utilization for these services may make gathering information on the 

appropriate physician work and direct PE inputs difficult. We request recommendations from 

the AMA RUC and other public commenters, and appreciate efforts expended to provide RVU 

and input recommendations to CMS for these lower volume services. Because survey sample 

sizes could be small for these lower volume services, we encourage the use of valid and reliable 

alternative data sources and methodologies when developing recommended values. In sum, we 

propose to review Harvard-valued CPT codes with annual allowed charges of $10 million or 

more as a part of the potentially misvalued codes initiative. Table 7 lists the codes that meet 

these criteria using CY 2011 Medicare claims data. 
CMS-1590-P 72 

TABLE 7: Harvard-valued CPT Codes with Annual Allowed Charges ≥$10,000,000 

CPT Code Short Descriptor 

13152* Repair of wound or lesion 

27446 Revision of knee joint 

29823 Shoulder arthroscopy/surgery 

36215** Place catheter in artery 

36245** Ins cath abd/l-ext art 1st

43264** Endo cholangiopancreatograph 

50360 Transplantation of kidney 

52353* Cystouretero w/lithotripsy 

64450* N block other peripheral 

64590 Insrt/redo pn/gastr stimul 

66180 Implant eye shunt 

67036 Removal of inner eye fluid 

67917 Repair eyelid defect 

92286** Internal eye photography 

92982* Coronary artery dilation 

95860* Muscle test one limb 

*Scheduled for CY 2012 AMA RUC Review 

**Referred by the AMA RUC to the CPT Editorial Panel 

(2) Review of Services with Stand Alone PE Procedure Time 

Improving the accuracy of procedure time assumptions used in PFS ratesetting continues 

to be a high priority of the potentially misvalued codes initiative. Procedure time is a critical 

measure of the resources typically used in furnishing particular services to Medicare 

beneficiaries, and procedure time assumptions are an important component in the development 

of work and PE RVUs. Discussions in the academic community have indicated that procedure 

times used for PFS ratesetting are overstated (McCall, N., J. Cromwell, et al. (2006). “Validation 

of physician survey estimates of surgical time using operating room logs.” Med Care Res Rev

63(6): 764-777. Cromwell, J., S. Hoover, et al. (2006). “Validating CPT typical times for 

Medicare office evaluation and management (E/M) services.” Med Care Res Rev 63(2): 236-

255. Cromwell, J., N. McCall, et al. (2010). “Missing productivity gains in the Medicare 
CMS-1590-P 73 

physician fee schedule: where are they?” Med Care Res Rev 67(6): 236-255.) MedPAC and 

others have emphasized the importance of using the best available procedure time information in 

establishing accurate PFS payment rates. (MedPAC, Report to the Congress: Aligning 

Incentives in Medicare, June 2010, p. 230) 

In recent years, CMS and the AMA RUC have taken steps to consider the accuracy of 

available data regarding procedure times used in the valuation of the physician work component 

of PFS payment. Generally, the AMA RUC derives estimates of physician work time from 

survey responses, and the AMA RUC reviews and analyzes those responses as part of its process 

for developing a recommendation for physician work. These procedure time assumptions are 

also used in determining the appropriate direct PE input values used in developing nonfacility PE 

RVUs. Specifically, physician intra-service time serves as the basis for allocating the 

appropriate number of minutes within the service period to account for the time used in 

furnishing the service to the patient. The number of intra-service minutes, or occasionally a 

particular proportion thereof, is allocated to both the clinical staff that assists the physician in 

furnishing the service and to the equipment used by either the physician or the staff in furnishing 

the service. This allocation reflects only the time the beneficiary receives treatment and does not 

include resources used immediately prior to or following the service. Additional minutes are 

often allocated to both clinical labor and equipment resources in order to account for the time 

used for necessary preparatory tasks immediately preceding the procedure or tasks typically 

performed immediately following it. For codes without physician work, the procedure times 

assigned to the direct PE inputs for such codes assume that the clinical labor performs the 

procedure. For these codes, the number of intra-service minutes assigned to clinical staff is 

independent and not based on any physician intra-service time assumptions. Consequently, the 
CMS-1590-P 74 

procedure time assumptions for these kinds of services have not been subject to all of the same 

mechanisms recently used by the AMA RUC and physician community in providing 

recommendations to CMS, and by CMS in the valuation of the physician work component of 

PFS payment. These independent clinical labor time assumptions largely determine the RVUs 

for the procedure. To ensure that procedure time assumptions are as accurate as possible across 

the Medicare PFS, we believe that codes without physician work should be examined with the 

same degree of scrutiny as services with physician work. 

For CY 2012, a series of radiation treatment services were reviewed as part of the 

potentially misvalued code initiative. Among these were intensity modulated radiation therapy 

(IMRT) delivery services and stereotactic body radiation therapy (SBRT) delivery services 

reported with CPT codes 77418 (Intensity modulated treatment delivery, single or multiple 

fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per 

treatment session) and 77373 (Stereotactic body radiation therapy, treatment delivery, per 

fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions), 

respectively. CPT code 77418 (IMRT treatment delivery) had been identified as potentially 

misvalued based on Medicare utilization data that indicated both fast growth in utilization and 

frequent billing with other codes. We identified this code as potentially misvalued in the CY 

2009 PFS proposed rule (73 FR 38586). CPT code 77373 (SBRT treatment delivery) had been 

identified as potentially misvalued by the RUC as a recently established code describing services 

that use new technologies. There is no physician work associated with either of these codes 

since other codes are used to bill for planning, dosimetry, and radiation guidance. Both codes 

are billed per treatment session. Because the physician work associated with these treatments is 

reported using codes distinct from the treatment delivery, the primary determinant of PE RVUs 
CMS-1590-P 75 

for these codes is the number of minutes allocated for the procedure time to both the clinical 

labor (radiation therapist) and the resource-intensive capital equipment included as direct PE 

inputs. 

In the CY 2012 PFS final rule with comment period, we received and accepted without 

refinement PE recommendations from the AMA RUC for these two codes. (We received the 

recommendation for CPT code 77418 (IMRT treatment delivery) too late in 2010 to be evaluated 

for CY 2011 and it was therefore included in the CY 2012 rulemaking cycle.) The AMA RUC 

recommended minor revisions to the direct PE inputs for the code to eliminate duplicative 

clinical labor, supplies, and equipment to account for the frequency with which the code was 

billed with other codes. For CPT code 77373 (SBRT treatment delivery), the RUC 

recommended no significant changes to the direct PE inputs. 

Subsequent to the publication of the final rule, the AMA RUC and other stakeholders 

informed CMS that the direct PE input recommendation forwarded to CMS for IMRT treatment 

delivery (CPT code 77418) inadvertently omitted seven equipment items typically used in 

furnishing the service. These items had been used as direct PE inputs for the code prior to CY 

2012. There is broad agreement among stakeholders that these seven equipment items are 

typically used in furnishing the services described by CPT code 77418. We were unable to 

reincorporate the items for CY 2012. These omitted items are listed in Table 8. In consideration 

of the comments from the AMA RUC and other stakeholders, we are proposing to include the 

seven equipment items omitted from the RUC recommendation for CPT code 77418. These 

proposed adjustments are also reflected in the CY 2013 proposed direct PE input database, 

available on the CMS Website under the downloads for the CY 2013 PFS proposed rule at 

http://www.cms.gov/PhysicianFeeSched/. We note that the proposed PE RVUs included in 
CMS-1590-P 76 

Addendum B to this proposed rule reflect the RVUs that result from application of these 

proposals. 

 

TABLE 8: Equipment Inputs Omitted From RUC Recommendation for CPT Code 77418 

(IMRT Treatment Delivery) 

Equipment 

Code Equipment Description 

ED011 computer system, record and verify 

ED035 video camera 

ED036 video printer, color (Sony medical grade) 

EQ139 intercom (incl. master, pt substation, power, wiring) 

ER006 IMRT physics tools 

ER038 isocentric beam alignment device 

ER040 laser, diode, for patient positioning (Probe) 

It has come to our attention that there are wide discrepancies between the procedure time 

assumptions used in establishing nonfacility PE RVUs for these services and the procedure times 

made widely available to Medicare beneficiaries and the general public. Specifically, the direct 

PE inputs for IMRT treatment delivery (CPT code 77418) reflect a procedure time assumption of 

60 minutes. These procedure minutes were first assigned to the code for CY 2002 based on a 

recommendation from the AMA RUC indicating that the typical treatment time for the IMRT 

patient was 40 to 70 minutes. The most recent RUC recommendation that CMS received for CY 

2012 rulemaking supported the procedure time assumption of 60 minutes. 

Information publicly available to Medicare beneficiaries and the general public clearly 

indicates that IMRT sessions typically last between 10 and 30 minutes. For example, the 

American Society for Radiation Oncology (ASTRO) publishes a patient fact sheet that explains 

that for all external beam radiation therapy, including IMRT, “treatment is delivered in a series 

of daily sessions, each about 15 minutes long.” [“Radiation Therapy for Prostate Cancer: Facts 
CMS-1590-P 77 

to Help Patients Make an Informed Decision” available for purchase at 

www.astro.org/MyASTRO/Products/Product.aspx?AstroID=6901.] This fact sheet is intended 

for patients with prostate cancer, the typical diagnosis for Medicare beneficiaries receiving 

IMRT. Similarly, the American College of Radiology (ACR) and the Radiological Society of 

North America (RSNA) co-sponsor a website for patients called http://radiologyinfo.org that 

states that IMRT “treatment sessions usually take between 10 and 30 minutes.” 

The direct PE inputs for SBRT treatment delivery (CPT code 77373) reflect a procedure 

time assumption of 90 minutes. These procedure minutes were first assigned to the code for CY 

2007 based on a recommendation from the AMA RUC. The most recent RUC recommendation 

that CMS received for CY 2012 rulemaking supported continuing that procedure time 

assumption. 

In 2012, information publicly available to Medicare beneficiaries and the general public 

states that SBRT treatment typically lasts no longer than 60 minutes. For example, the American 

College of Radiology (ACR) and the Radiological Society of North America (RSNA) website, 

http://radiologyinfo.org, states that SBRT “treatment can take up to one hour.” 

Given the importance of the procedure time assumption in the development of RVUs for 

these services, using the best available information is critical to ensuring that these services are 

valued appropriately. We have no reason to believe that information medical societies and 

practitioners offer to their cancer patients regarding the IMRT or SBRT treatment experience is 

inaccurate or atypical. Therefore, we believe that the typical procedure time for IMRT delivery 

is between 10 and 30 minutes and that the typical procedure time for SBRT delivery is under 60 

minutes. The services are currently valued using procedure time assumptions of 60 and 90 

minutes, respectively. We believe these procedure time assumptions, distinct from necessary 
CMS-1590-P 78 

preparatory or follow-up tasks by the clinical labor, are clearly outdated and need to be updated 

using the best information available. 

While we generally have not used publicly available resources to establish procedure 

time assumptions, we believe that the procedure time assumptions used in setting payment rates 

for the Medicare PFS should be derived from the most accurate information available. In the 

case of these services, we believe that the need to reconcile the vast discrepancies between our 

existing assumptions and more accurate information outweighs the potential value in maintaining 

relativity offered by only considering data from one source. We are proposing to adjust the 

procedure time assumption for IMRT delivery (CPT code 77418) to 30 minutes. We are 

proposing to adjust the procedure time assumption for SBRT delivery (CPT code 77373) to 60 

minutes. These procedure time assumptions reflect the maximum number of minutes reported as 

typical in publicly available information. We note that in the case of CPT code 77418, the 

‘accelerator, 6-18 MV’ (ER010) and the ‘collimator, multileaf system w-autocrane’ (ER017) are 

used throughout the procedure and currently have no minutes allocated for preparing the 

equipment, positioning the patient, or cleaning the room. Since these clinical labor tasks are 

associated with related codes typically reported at the same time, we are also proposing to 

allocate minutes to these equipment items to account for their use immediately before and 

following the procedure. All of these proposed adjustments are reflected in the CY 2013 

proposed direct PE input database, available on the CMS Website under the downloads for the 

CY 2013 PFS proposed rule at http://www.cms.gov/PhysicianFeeSched/. We also note that the 

proposed PE RVUs included in Addendum B to this proposed rule reflect the RVUs that result 

from the application of this proposal. We request recommendations from the AMA RUC and 

other public commenters on the direct PE inputs for these services 
CMS-1590-P 79 

While we recognize that using these procedure time assumptions will result in payment 

reductions for these particular services, we believe such changes are necessary to appropriately 

value these services. Recent attention from popular media sources like the Wall Street Journal 

(online.wsj.com/article/SB10001424052748703904804575631222900534954.html December 

7,2010 ) and the Washington Post (www.washingtonpost.com/wpdyn/content/article/2011/02/28/AR2011022805378.html) February 28, 2011 has encouraged us 

to consider the possibility that potential overuse of IMRT services may be partially attributable 

to financial incentives resulting from inappropriate payment rates. In its 2010 Report to 

Congress, MedPAC referenced concerns that financial incentives may influence how cancer 

patients are treated. In the context of the growth of ancillary services in physicians’ offices, 

MedPAC recommended that improving payment accuracy for discrete services should be a 

primary tool used by CMS to mitigate incentives to increase volume (Report to Congress: 

Aligning Incentives in Medicare, June 2010, p. 225). We note that in recent years, PFS 

nonfacility payment rates for IMRT treatment delivery have exceeded the Medicare payment rate 

for the same service paid through the hospital Outpatient Prospective Payment System (OPPS). 

We believe that such high-volume services that are widely furnished in both nonfacility and 

facility settings are highly unlikely to be more resource-intensive in freestanding radiation 

therapy centers or physicians’ offices than when furnished in facilities like hospitals that 

generally incur higher overhead costs, maintain a 24 hour, 7 day per week capacity, are generally 

paid in larger bundles, and generally furnish services to higher acuity patients than the patients 

who receive services in physician offices or free-standing clinics. Given that the OPPS payment 

rates are based on auditable data on hospital costs, we believe the seemingly counterintuitive 

relationship between the OPPS and nonfacility PFS payment rates reflects inappropriate 
CMS-1590-P 80 

assumptions within the current direct PE inputs for CPT code 77418. The AMA RUC’s most 

recent direct PE input recommendations reflect the same procedure time assumptions used in 

developing the recommendations for CY 2002. As we explained above, we do not understand 

how the AMA RUC can recommend these assumptions in the context of the procedure time 

information available to the general public. We believe that using procedure time assumptions 

that reflect the maximum times reported as typical to Medicare beneficiaries will improve the 

accuracy of those inputs and the resulting nonfacility payment rates. 

These two treatment delivery codes are PE only codes and are fairly unique in that the 

resulting RVUs are largely comprised of resources for staff and equipment based on the minutes 

associated with clinical labor. There are several other codes on the PFS established through the 

same methodology. As we previously stated, we believe that the procedure time assumptions for 

these kinds of services have not been subject to all of the same mechanisms recently used by 

CMS in the valuation of the physician work component of PFS payment. In light of observations 

about publicly available procedure times for CPT codes 77418 (IMRT treatment delivery) and 

77373 (SBRT treatment delivery) and public awareness of potential adverse financial incentives 

associated with IMRT treatment delivery in particular, we believe that similar codes are 

potentially misvalued. 

Therefore, consistent with the requirement in section 1848(c)(2)(K)(ii) of the Act to 

examine other codes determined to be appropriate by the Secretary, we are proposing to review 

and make adjustments to CPT codes with stand alone procedure time assumptions used in 

developing nonfacility PE RVUs. These procedure time assumptions are not based on physician 

time assumptions. We are prioritizing for review CPT codes that have annual Medicare allowed 

charges of $100,000 or more, include direct equipment inputs that amount to $100 or more, and 
CMS-1590-P 81 

have PE procedure times of greater than 5 minutes. At this time, we are not including in this 

category services with payment rates subject to the OPPS cap (as specified in the statute under 

section 1848(b)(4) of the Act and listed in Addendum G to this proposed rule) or services with 

PE minutes established through code descriptors. (For example, an overnight monitoring code 

might contain 480 minutes of monitoring equipment time to account for 8 hours of overnight 

monitoring.) The CPT codes meeting these criteria appear in Table 9. We recognize that there 

are other CPT codes that are valued in the same manner. We may consider evaluating those 

services as potentially misvalued codes in future rulemaking. 

For the services in Table 9, we request recommendations from the AMA RUC and other 

public commenters on the appropriate direct PE inputs for these services. We encourage the use 

of valid and reliable alternative data sources when developing recommended values, including 

electronic medical records and other independent data sources. We note that many of the CPT 

codes in Table 9 have been identified through other potentially misvalued code screens and have 

been recently reviewed. Given our observed concerns with the inputs for the recently reviewed 

IMRT and SBRT direct PE inputs discussed above, we believe it is necessary to re-review other 

recently reviewed services with stand alone PE procedure time. 

TABLE 9: Services with Stand Alone PE Procedure Time 

CPT 

Code Short Descriptor 

77280 Set radiation therapy field 

77285 Set radiation therapy field 

77290 Set radiation therapy field 

77301 Radiotherapy dose plan imrt 

77338 Design mlc device for imrt 

77372 Srs linear based 

77373 Sbrt delivery 

77402 Radiation treatment delivery 

77403 Radiation treatment delivery 

77404 Radiation treatment delivery 
CMS-1590-P 82 

CPT 

Code Short Descriptor 

77406 Radiation treatment delivery 

77407 Radiation treatment delivery 

77408 Radiation treatment delivery 

77409 Radiation treatment delivery 

77412 Radiation treatment delivery 

77413 Radiation treatment delivery 

77414 Radiation treatment delivery 

77416 Radiation treatment delivery 

77418 Radiation tx delivery imrt 

77600 Hyperthermia treatment 

77785 Hdr brachytx 1 channel 

77786 Hdr brachytx 2-12 channel 

77787 Hdr brachytx over 12 chan 

88348 Electron microscopy 

c. Services with Anomalous Time 

Each year when we publish the PFS proposed and final rules, we publish on the CMS 

Website several files that support annual PFS rate-setting. One of these supporting files is the 

physician time file, which lists the physician time associated with the HCPCS codes on the PFS. 

The physician time file associated with this PFS proposed rule is available on the CMS Website 

under the downloads for the CY 2013 PFS proposed rule at 

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

In our review of potentially misvalued codes and their inputs, we became aware of 

several HCPCS codes that have anomalous times in our physician time file. Physician work is a 

measure of physician time and intensity, so there should be no services that have payable 

physician work RVUs but no physician time in the time file, and there should be no payable 

services with physician time in the time file and no physician work RVUs. For CY 2013 we are 

proposing to make the physician time file changes detailed below to address these anomalous 

time file entries. 
CMS-1590-P 83 

(1) Review of Services with Physician Work and No Listed Physician Time 

CPT code 94014 (Patient-initiated spirometric recording per 30-day period of time; 

includes reinforced education, transmission of spirometric tracing, data capture, analysis of 

transmitted data, periodic recalibration and physician review and interpretation) has a physician 

work RVU of 0.52 and is currently listed with 0 physician time. CPT code 94014 is a global 

service that includes CPT code 94015 (Patient-initiated spirometric recording per 30-day period 

of time; recording (includes hook-up, reinforced education, data transmission, data capture, trend 

analysis, and periodic recalibration)) (the technical component), and CPT code 94016 (Patientinitiated spirometric recording per 30-day period of time; physician review and interpretation 

only) (the professional component). We believe it is appropriate for the physician time of CPT 

code 94014 to match the physician time of the code’s component professional service—CPT 

code 94016. As such, for CPT code 94014 for CY 2013, we are proposing to assign 2 minutes of 

pre-service evaluation time, and 20 minutes of intra-service time, which matches the times 

associated with CPT code 94016. These proposed adjustments are reflected in the physician 

time file associated with this proposed rule, available on the CMS Website under the downloads 

for the CY 2013 PFS proposed rule at http://www.cms.gov/PhysicianFeeSched/.

HCPCS codes G0117 (Glaucoma screening for high risk patients furnished by an 

optometrist or ophthalmologist) and G0118 (Glaucoma screening for high risk patient furnished 

under the direct supervision of an optometrist or ophthalmologist) both have physician work 

RVUs (0.45, and 0.17, respectively), but neither code is included in the physician time file. 

HCPCS codes G0117 and G0118 have a PFS procedure status indicator of T indicating that these 

services are only paid if there are no other services payable under the PFS billed on the same 

date by the same provider. 
CMS-1590-P 84 

In the CY 2002 PFS final rule (66 FR 55274), we crosswalked the physician work of 

HCPCS code G0117 from CPT code 99212 (Level 2 office or other outpatient visit, established 

patient), and we crosswalked the physician work of HCPCS code G0118 from CPT code 99211 

(Level 1 office or other outpatient visit, established patient). Based on these finalized physician 

work crosswalks, we propose to assign HCPCS code G0117 physician times matching CPT code 

99212, and HCPCS code G0118 physician times matching CPT code 99211. Specifically, we 

are proposing 2 minutes of pre-service time, 10 minutes of intra-service time, and 4 minutes of 

immediate post-service time for HCPCS code G0117, and 5 minutes of intra-service time, and 2 

minutes of immediate post-service time for HCPCS code G0118. These proposed adjustments 

are reflected in the physician time file associated with this proposed rule, available on the CMS 

Website under the downloads for the CY 2013 PFS proposed rule at 

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

HCPCS code G0128 (Direct (face-to-face with patient) skilled nursing services of a 

registered nurse provided in a comprehensive outpatient rehabilitation facility, each 10 minutes 

beyond the first 5 minutes) currently has a physician work RVU ( 0.08), but is not listed in the 

physician time file. After review of this HCPCS code, we do not believe that HCPCS code 

G0128 describes a service that includes physician work. Time for a registered nurse to furnish 

the service is included in the PE for the code. As such, for CY 2013, we propose to remove the 

physician work RVU for HCPCS code G0128. HCPCS code G0128 will continue to have PE 

and malpractice expense RVUs. 

HCPCS codes G0245 (Initial physician evaluation and management of a diabetic patient 

with diabetic sensory neuropathy resulting in a loss of protective sensation (LOPS) which must 

include: (1) the diagnosis of LOPS; (2) a patient history; (3) a physical examination that consists 
CMS-1590-P 85 

of at least the following elements: (a) visual inspection of the forefoot, hindfoot and toe web 

spaces; (b) evaluation of a protective sensation; (c) evaluation of foot structure and 

biomechanics; (d) evaluation of vascular status and skin integrity; and (e) evaluation and 

recommendation of footwear; and (4) patient education), G0246 (Follow-up physician evaluation 

and management of a diabetic patient with diabetic sensory neuropathy resulting in a loss of 

protective sensation (LOPS) to include at least the following: (1) a patient history; (2) a physical 

examination that includes: (a) visual inspection of the forefoot, hindfoot and toe web spaces; (b) 

evaluation of protective sensation; (c) evaluation of foot structure and biomechanics; (d) 

evaluation of vascular status and skin integrity; and (e) evaluation and recommendation of 

footwear; and (3) patient education), and G0247 (Routine foot care by a physician of a diabetic 

patient with diabetic sensory neuropathy resulting in a loss of protective sensation (LOPS) to 

include, the local care of superficial wounds (that is, superficial to muscle and fascia) and at least 

the following if present: (1) local care of superficial wounds; (2) debridement of corns and 

calluses; and (3) trimming and debridement of nails) have physician work RVUs of 0.88, 0.45, 

and 0.50, respectively, but are not listed in the physician time file. HCPCS codes G0245, 

G0246, and G0247 have a procedure status indicator of R on the PFS indicating that coverage of 

these services is restricted. 

In the CY 2003 PFS final rule (67 FR 79990), we crosswalked the physician work of 

HCPCS code G0245 from CPT code 99202 (Level 2 office or other outpatient visits, new 

patient), we crosswalked the physician work of HCPCS code G0246 from CPT code 99212, and 

we crosswalked the physician work of HCPCS code G0257 from CPT code 11040 

(Debridement; skin; partial thickness). Based on these finalized physician work crosswalks, we 

propose to assign HCPCS code G0245 physician times matching CPT code 99202, HCPCS code 
CMS-1590-P 86 

G0246 physician times matching CPT code 99212, and HCPCS code G0247 physician times 

matching CPT code 11040. Specifically, for HCPCS code G0245 we are proposing 2 minutes of 

pre-service time, 15 minutes of intra-service time, and 5 minutes of immediate post-service time. 

For HCPCS code G0246 we are proposing 2 minutes of pre-service time, 10 minutes of intraservice time, and 4 minutes of immediate post-service time. For HCPCS code G0247 we are 

proposing 7 minutes of pre-service time, 10 minutes of intra-service time, and 7 minutes of 

immediate post-service time. These proposed adjustments are reflected in the physician time file 

associated with this proposed rule, available on the CMS Website under the downloads for the 

CY 2013 PFS proposed rule at http://www.cms.gov/PhysicianFeeSched/. 

HCPCS code G0250 (Physician review, interpretation, and patient management of home 

INR (International Normalized Ratio) testing for patient with either mechanical heart valve(s), 

chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; 

testing not occurring more frequently than once a week; billing units of service include 4 tests) 

has a physician work RVU of 0.18 but is not listed in the physician time file. HCPCS code 

G0250 has a procedure status indicator of R on the PFS indicating that coverage of this service is 

restricted. In the CY 2003 final rule (67 FR 79991), we assigned HCPCS code G0250 a work 

RVU of 0.18, which corresponds to the work RVU of CPT code 99211. While we did not 

articulate this as a direct crosswalk in the CY 2003 final rule, after clinical review we believe 

that HCPCS code G0250 continues to require similar work as CPT code 99211, and should have 

the same amount of physician time as CPT code 99211. As such, we are proposing to assign 

HCPCS code G0250 the same physician time as CPT code 99211. Specifically, for HCPCS code 

G0250 we are proposing 5 minutes of intra-service time and 2 minutes of immediate post-service 

time. These proposed adjustments are reflected in the physician time file associated with this 
CMS-1590-P 87 

proposed rule, available on the CMS Website under the downloads for the CY 2013 PFS 

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

During our annual review of new, revised, and potentially misvalued CPT codes, the 

assessment of physician time used to furnish a service is an important part of the clinical review 

when determining the appropriate work RVU for a service. However, the time in the physician 

time file is not used to automatically adjust the physician work RVUs outside of that clinical 

review process. As such, the proposed addition of physician time to the HCPCS codes discussed 

above will have no impact on the current physician work RVUs for these services. 

The time data in the physician time file is used in the PE methodology described in 

section II.A.2. In creating the indirect practice cost index (IPCI), we calculate specialty-specific 

aggregate pools of indirect PE for all PFS services for that specialty by adding the product of the 

indirect PE/HR for the specialty, the physician time for the service, and the specialty’s utilization 

for the service across all services furnished by the specialty. The proposed addition of physician 

time to the HCPCS codes discussed above will affect the aggregate pools of indirect PE at the 

specialty level. However because the services discussed above have low utilization and low total 

time, the impact of the physician time changes on the IPCI is negligible, and likely would have a 

modest impact if any on the PE RVUs at the individual code level. 

(2) Review of Services with Stand Alone PE Procedure Time 

There are a number of services that have no physician work RVUs, yet include physician 

time in the physician time file. Many of these services are not payable under the PFS or are 

contractor priced services where the physician time is not used to nationally price the services on 

the PFS. We are not proposing to remove the physician time from the time file for these services 

as the time has no effect on the calculation of RVUs for the PFS. However, there are several 
CMS-1590-P 88 

CPT codes, listed in Table 10, that are payable under the PFS and have no physician work RVUs 

yet include time in the physician time file. We are proposing to remove the physician time from 

the time file for these seven CPT codes. These proposed adjustments are reflected in the 

physician time file associated with this proposed rule, available on the CMS Website under the 

downloads for the CY 2013 PFS proposed rule at http://www.cms.gov/PhysicianFeeSched/. 

TABLE 10: Payable CPT Codes with Physician Time and No Physician Work 

CPT 

Code 

Short Descriptor PFS Procedure Status CY 2012 Total 

Physician Time 

22841 Insert spine fixation 

device 

B (Bundled, not separately 

payable) 

5 minutes 

51798 Us urine capacity measure A (Active, payable) 9 minutes 

95990 Spin/brain pump refill & 

main 

A (Active, payable) 40 minutes 

96904 Whole body photography R (Restricted coverage) 80 minutes 

96913 Photochemotherapy uv-a 

or b 

A (Active, payable) 90 minutes 

97545 Work hardening R(Restricted coverage) 120 minutes 

97602 Wound(s) care nonselective B (Bundled, not separately 

payable) 

36 minutes 

As mentioned above and as discussed in section II.A.2. of this proposed rule, to create the 

IPCI used in the PE methodology, we calculate specialty-specific aggregate pools of indirect PE 

for all PFS services for that specialty by adding the product of the indirect PE/HR for the 

specialty, the physician time for the service, and the specialty’s utilization for the service across 

all services performed by the specialty. The proposed removal of physician time from the CPT 

codes discussed above will affect the aggregate pools of indirect PE at the specialty level. 

However because the services discussed above have low utilization and/or low total time, the 

impact of the physician time changes on the IPCI is negligible, and likely would have a modest 

impact if any on the PE RVUs at the individual code level.
CMS-1590-P 89 

4. Expanding the Multiple Procedure Payment Reduction Policy 

Medicare has long employed multiple procedure payment reduction (MPPR) policies to 

adjust payment to more appropriately reflect reduced resources involved with furnishing the 

service for certain sets of services frequently furnished together. Under these policies, we reduce 

payment for the second and subsequent services within the same MPPR category furnished in the 

same session or same day. These payment reductions reflect efficiencies that typically occur in 

either the practice expense (PE) or professional work or both when services are furnished 

together. With the exception of a few codes that are always reported along with another code, 

the Medicare PFS values services independently to recognize relative resources involved when 

the service is the only one furnished in a session. While our general policy for MPPRs precedes 

the Affordable Care Act, this payment policy approach addresses the fourth category of 

potentially misvalued codes identified in section 1848(c)(2)(K) of the Act, as added by section 

3134(a) of the Affordable Care Act, which is “multiple codes that are frequently billed in 

conjunction with furnishing a single service” (see 75 FR 73216). 

For CY 2013, we are proposing to continue our work to recognize resource efficiencies 

when certain services are furnished together. We are proposing to apply an MPPR to the 

technical component (TC) of certain diagnostic tests. As discussed in the CY 2012 final rule 

with comment period (76 FR 73079), we are also proceeding with applying the current MPPR 

policy for imaging services to services furnished in the same session by physicians in the same 

group practice. 

a. Background 

Medicare has a longstanding policy to reduce payment by 50 percent for the second and 

subsequent surgical procedures furnished to the same patient by a single physician or physicians 
CMS-1590-P 90 

in the same group practice on the same day, largely based on the presence of efficiencies in the 

PE and pre- and post-surgical physician work. Effective January 1, 1995, the MPPR policy, with 

this same percentage reduction, was extended to nuclear medicine diagnostic procedures 

(CPT codes 78306, 78320, 78802, 78803, 78806, and 78807). In the CY 1995 PFS final rule 

with comment period (59 FR 63410), we indicated that we would consider applying the policy to 

other diagnostic tests in the future. 

Consistent with recommendations of MedPAC in its March 2005 Report to the Congress 

on Medicare Payment Policy, for CY 2006 PFS, we extended the MPPR policy to the TC of 

certain diagnostic imaging procedures furnished on contiguous areas of the body in a single 

session (70 FR 70261). This MPPR recognizes that for the second and subsequent imaging 

procedures furnished in the same session, there are some efficiencies in clinical labor, supplies, 

and equipment time. In particular, certain clinical labor activities and supplies are not duplicated 

for subsequent imaging services in the same session and, because equipment time and indirect 

costs are allocated based on clinical labor time, we also reduced those accordingly. 

The imaging MPPR policy originally applied to computed tomography (CT) and 

computed tomographic angiography (CTA), magnetic resonance imaging (MRI) and magnetic 

resonance angiography (MRA), and ultrasound services within 11 families of codes based on 

imaging modality and body region and only applied to procedures furnished in a single session 

involving contiguous body areas within a family of codes, not across families. Additionally, the 

MPPR policy originally applied to TC-only services and to the TC of global services, and not to 

professional component (PC) services. 

There have been several revisions to this policy since it was originally adopted. Under 

the current imaging MPPR policy, full payment is made for the TC of the highest paid procedure, 
CMS-1590-P 91 

and payment for the TC is reduced by 50 percent for each additional procedure subject to this 

MPPR policy. We originally planned to phase in the imaging MPPR policy over a 2-year period, 

with a 25 percent reduction in CY 2006 and a 50 percent reduction in CY 2007 (70 FR 70263). 

However, the Deficit Reduction Act of 2005 (DRA) (Pub. L. 109–171) amended the statute to 

place a cap on the PFS payment amount for most imaging procedures at the amount paid under 

the hospital outpatient prospective payment system (OPPS). In view of the new OPPS payment 

cap added by the DRA, we decided in the PFS final rule with comment period for 2006 that it 

would be prudent to retain the imaging MPPR at 25 percent while we continued to examine the 

appropriate payment levels (71 FR 69659). The DRA also exempted reduced expenditures 

attributable to the imaging MPPR policy from the PFS BN provision. Effective July 1, 2010, 

section 1848(b)(4)(C) of the Act, as added by section 3135(b)(1) of the Affordable Care Act 

increased the MPPR on the TC of imaging services under the policy established in the CY 2006 

PFS final rule with comment period from 25 to 50 percent. Section 1848(c)(2)(B)(v)(IV) of the 

Act, as added by section 3135(b)(2) of the Affordable Care Act exempted the reduced 

expenditures attributable to this further change from the PFS BN provision. 

In the July 2009 U.S. Government Accountability Office (GAO) report entitled, 

"Medicare Physician Payments: Fees Could Better Reflect Efficiencies Achieved when Services 

are Provided Together," the GAO recommended that we take further steps to ensure that fees for 

services paid under the PFS reflect efficiencies that occur when services are furnished by the 

same physician to the same beneficiary on the same day. The GAO recommended the following: 

(1) expanding the existing imaging MPPR policy for certain services to the PC to reflect 

efficiencies in physician work for certain imaging services; and (2) expanding the MPPR to 

reflect PE efficiencies that occur when certain nonsurgical, nonimaging services are furnished 
CMS-1590-P 92 

together. The GAO report also encouraged us to focus on service pairs that have the most impact 

on Medicare spending. 

In its March 2010 report, MedPAC noted its concerns about mispricing of services under 

the PFS. MedPAC indicated that it would explore whether expanding the unit of payment 

through packaging or bundling would improve payment accuracy and encourage more efficient 

use of services. In the CYs 2009 and 2010 PFS proposed rules (73 FR 38586 and 74 FR 33554, 

respectively), we stated that we planned to analyze nonsurgical services commonly furnished 

together (for example, 60 to 75 percent of the time) to assess whether an expansion of the MPPR 

policy could be warranted. MedPAC encouraged us to consider duplicative physician work, as 

well as PE, in any expansion of the MPPR policy. 

Section 1848(c)(2)(K) of the Act specifies that the Secretary shall identify potentially 

misvalued codes by examining multiple codes that are frequently billed in conjunction with 

furnishing a single service, and review and make appropriate adjustments to their relative values. 

As a first step in applying this provision, in the CY 2010 final rule with comment period, we 

implemented a limited expansion of the imaging MPPR policy to additional combinations of 

imaging services. 

 Effective January 1, 2011, the imaging MPPR applies regardless of code family; that is, 

the policy applies to multiple imaging services furnished within the same family of codes or 

across families. This policy is consistent with the standard PFS MPPR policy for surgical 

procedures that does not group procedures by body region. The current imaging MPPR policy 

applies to CT and CTA, MRI and MRA, and ultrasound procedures furnished to the same patient 

in the same session, regardless of the imaging modality and is not limited to contiguous body 

areas. 
CMS-1590-P 93 

As we noted in the CY 2011 PFS final rule with comment period (75 FR 73228), while 

section 1848(c)(2)(B)(v)(VI) of the Act specifies that reduced expenditures attributable to the 

increase in the imaging MPPR from 25 to 50 percent (effective for fee schedules established 

beginning with 2010 and for services furnished on or after July 1, 2010) are excluded from the 

PFS BN adjustment, it does not apply to reduced expenditures attributable to our policy change 

regarding additional code combinations across code families (non-continguous body areas) that 

are subject to BN under the PFS. The complete list of codes subject to the CY 2011 MPPR 

policy for diagnostic imaging services is included in Addendum F. 

As a further step in applying the provisions of section 1848(c)(2)(K) of the Act, on 

January 1, 2011, we implemented an MPPR for therapy services. The MPPR applies to 

separately payable "always therapy" services, that is, services that are only paid by Medicare 

when furnished under a therapy plan of care. As we explained in the CY 2011 PFS final rule 

with comment period (75 FR 73232), the therapy MPPR does not apply to contractor-priced 

codes, bundled codes, and add-on codes. The complete list of codes subject to the MPPR policy 

for therapy services is included in Addendum H. 

This MPPR for therapy services was first proposed in the CY 2011 proposed rule 

(75 FR 44075) as a 50 percent payment reduction to the PE component of the second and 

subsequent therapy services for multiple "always therapy" services furnished to a single patient 

in a single day. It applies to services furnished by an individual or group practice or "incident to" 

a physician's service. However, in response to public comments, in the CY 2011 PFS final rule 

with comment period (75 FR 73232), we adopted a 25 percent payment reduction to the PE 

component of the second and subsequent therapy services for multiple "always therapy" services 

furnished to a single patient in a single day. 
CMS-1590-P 94 

Subsequent to publication of the CY 2011 PFS final rule with comment period, section 3 

of the Physician Payment and Therapy Relief Act of 2010 (PPTRA) (Pub. L. 111-286) revised 

the payment reduction percentage from 25 percent to 20 percent for therapy services for which 

payment is made under a fee schedule under section 1848 (which are services furnished in office 

settings, or non-institutional services). The payment reduction percentage remains at 25 percent 

for therapy services furnished in institutional settings. Section 4 of the PPTRA exempted the 

reduced expenditures attributable to the therapy MPPR policy from the PFS BN provision. 

Under our current policy as amended by the PPTRA, for institutional services, full payment is 

made for the service or unit with the highest PE and payment for the PE component for the 

second and subsequent procedures or additional units of the same service is reduced by 

25 percent. For non-institutional services, full payment is made for the service or unit with the 

highest PE and payment for the PE component for the second and subsequent procedures or 

additional units of the same service is reduced by 20 percent. 

This MPPR policy applies to multiple units of the same therapy service, as well as to 

multiple different “always therapy” services, when furnished to the same patient on the same 

day. It applies to services furnished by an individual or group practice or "incident to" a 

physician's service. The MPPR applies when multiple therapy services are billed on the same 

date of service for one patient by the same practitioner or facility under the same National 

Provider Identifier (NPI), regardless of whether the services are furnished in one therapy 

discipline or multiple disciplines, including physical therapy, occupational therapy, or 

speech-language pathology. 

The MPPR policy applies in all settings where outpatient therapy services are paid under 

Part B. This includes both services that are furnished in the office setting and paid under the 
CMS-1590-P 95 

PFS, as well as institutional services that are furnished by outpatient hospitals, home health 

agencies, comprehensive outpatient rehabilitation facilities (CORFs), and other entities that are 

paid for outpatient therapy services at rates based on the PFS. 

In its June 2011 Report to Congress, MedPAC highlighted continued growth in ancillary 

services subject to the in-office ancillary services exception. The in-office ancillary exception to 

the general prohibition under section 1877 of the Act as amended by the Ethics in Patient 

Referrals Act, also known as the Stark law, allows physicians to refer Medicare patients for 

designated health services, including imaging, radiation therapy, home health care, durable 

medical equipment, clinical laboratory tests, and physical therapy, to entities with which they 

have a financial relationship under specific conditions. MedPAC recommended that we apply a 

MPPR to the PC of diagnostic imaging services furnished by the same practitioner in the same 

session as one means to curb excess self-referral for these services. The GAO already had made 

a similar recommendation in its July 2009 report. 

In continuing to apply the provisions of section 1848(c)(2)(K) of the Act, in the CY 2012 

final rule (76 FR 73071), we expanded the MPPR to the PC of Advanced Imaging Services (CT, 

MRI, and Ultrasound), that is, the same list of codes to which the MPPR on the TC of advanced 

imaging already applied (see Addendum F). Thus, this MPPR policy now applies to the PC and 

the TC of certain diagnostic imaging codes. Specifically, we expanded the payment reduction 

currently applied to the TC to apply also to the PC of the second and subsequent advanced 

imaging services furnished by the same physician (or by two or more physicians in the same 

group practice) to the same patient in the same session on the same day. However, in response to 

public comments, in the CY 2012 PFS final rule with comment period, we adopted a 25 percent 

payment reduction to the PC component of the second and subsequent imaging services. 
CMS-1590-P 96 

Under this policy, full payment is made for the PC of the highest paid procedure, and 

payment is reduced by 25 percent for the PC for each additional procedure furnished to the same 

patient in the same session. This policy was based on the expected efficiencies in furnishing 

multiple services in the same session due to duplication of physician work, primarily in the preand post-service periods, with smaller efficiencies in the intraservice period. 

This policy is consistent with the statutory requirement for the Secretary to identify, 

review, and adjust the relative values of potentially misvalued services under the PFS as 

specified by section 1848(c)(2)(K) of the Act. This policy is also consistent both with our 

longstanding policy on surgical and nuclear medicine diagnostic procedures, under which we 

apply a 50 percent payment reduction to second and subsequent procedures. Furthermore, it was 

responsive to continued concerns about significant growth in imaging spending, and to MedPAC 

(March 2010 and June 2011) and GAO (July 2009) recommendations regarding the expansion of 

MPPR policies under the PFS to account for additional efficiencies. 

In the CY 2012 proposed rule (76 FR 42812), we also invited public comment on the 

following MPPR policies under consideration. We noted that any proposals would be presented 

in future rulemaking and subject to further public comment: 

● Apply the MPPR to the TC of All Imaging Services. This approach would apply a 

payment reduction to the TC of the second and subsequent imaging services furnished in the 

same session. Such an approach could define imaging consistent with our existing definition of 

imaging for purposes of the statutory cap on PFS payment at the OPPS rate (including x-ray, 

ultrasound (including echocardiography), nuclear medicine (including positron emission 

tomography), magnetic resonance imaging, computed tomography, and fluoroscopy, but 

excluding diagnostic and screening mammography). Add-on codes that are always furnished 
CMS-1590-P 97 

with another service and have been valued accordingly could be excluded. 

Such an approach would be based on the expected efficiencies due to duplication of 

clinical labor activities, supplies, and equipment time when multiple services are furnished 

together. This approach would apply to approximately 530 HCPCS codes, including the 119 

codes to which the current imaging MPPR applies. Savings would be redistributed to other PFS 

services as required by the statutory PFS BN provision. 

● Apply the MPPR to the PC of All Imaging Services. This approach would apply a 

payment reduction to the PC of the second or subsequent imaging services furnished in the 

same encounter. Such an approach could define imaging consistent with our existing definition 

of imaging for the cap on payment at the OPPS rate. Add-on codes that are always furnished 

with another service and have been valued accordingly could be excluded. 

Such an approach would be based on efficiencies due to duplication of physician work 

primarily in the pre- and post-service periods, with smaller efficiencies in the intraservice period, 

when multiple services are furnished together. This approach would apply to approximately 530 

HCPCS codes, including the 119 codes to which the current imaging MPPR applies. Savings 

would be redistributed to other PFS services as required by the statutory PFS BN provision. 

● Apply the MPPR to the TC of All Diagnostic Tests. This approach would apply a 

payment reduction to the TC of the second and subsequent diagnostic tests (such as radiology, 

cardiology, audiology, etc.) furnished in the same encounter. Add-on codes that are always 

furnished with another service and have been valued accordingly could be excluded. 

Such an approach would be based on the expected efficiencies due to duplication of 

clinical labor activities, supplies, and equipment time when multiple services are furnished 

together. The approach would apply to approximately 700 HCPCS codes, including the 
CMS-1590-P 98 

approximately 560 HCPCS codes that are currently subject to the OPPS cap. The savings 

would be redistributed to other PFS services as required by the statutory PFS BN provision. 

b. MPPR Policy Clarifications 

(1) Apply the MPPR to Two Nuclear Medicine Procedures 

As indicated previously, effective January 1, 1995, we implemented an MPPR for six 

nuclear medicine codes. Under the current policy, full payment is made for the highest paid 

procedure, and payment is reduced by 50 percent for the second procedure furnished to the same 

patient on the same day. Due to a technical error, the MPPR is not being applied to CPT codes 

78306 (Bone imaging; whole body when followed by CPT code 78320 (Bone imaging; SPECT). 

We will apply the MPPR to these procedures effective January 1, 2013. 

(2) Apply the MPPR to the PC and TC of Advanced Imaging Procedures to Physicians in the 

Same Group Practice 

As indicated in the CY 2012 final rule (76 FR 73077-73079), we finalized a policy to 

apply the MPPR to the PC and TC of the second and subsequent advanced imaging procedures 

furnished to the same patient in the same session by a single physician or by multiple physicians 

in the same group practice. Due to operational limitations, we were not able to apply this MPPR 

to multiple physicians in the same group practice during CY 2012. In addition, after we issued 

the CY 2012 final rule with comment period, some stakeholders asserted that they had not 

commented on the application of the MPPR to physicians in the same group practice because 

that policy was not explicit in the CY 2012 proposed rule discussion expanding the MPPR for 

advanced imaging to the PC. We have resolved the operational problems and, therefore, for 

services furnished on or after January 1, 2013 we will apply the MPPR to both the PC and the 

TC of advanced imaging procedures to multiple physicians in the same group practice (same 
CMS-1590-P 99 

group NPI). Under this policy, the MPPR will apply when one or more physicians in the same 

group practice furnish services to the same patient, in the same session, on the same day. This 

policy is consistent with other PFS MPPR policies for surgical and therapy procedures. We 

continue to believe that the typical efficiencies achieved when the same physician is furnishing 

multiple procedures also accrue when different physicians in the same group furnish multiple 

procedures involving the same patient in the same session. It is our general intention to apply 

this and future MPPRs to services furnished by one or more physicians in the same group unless 

special circumstances warrant a more limited application. In such circumstances, we will note in 

our proposal that an MPPR does not apply to one or more physicians in the same group as other 

MPPR policies do. We continue to welcome public comment on this provision as it applies to 

advanced diagnostic imaging and to the MPPR policy generally. 

c. Proposed MPPR for the TC of Cardiovascular and Ophthalmology Services. 

As noted above, we continue to examine whether it would be appropriate to apply MPPR 

policies to other categories of services that are frequently billed together, including the TC for 

other diagnostic services. For CY 2013, we examined other diagnostic services to determine 

whether there typically are efficiencies in the technical component when multiple diagnostic 

services are furnished together on the same day. We have conducted an analysis of the most 

frequently furnished code combinations for all diagnostic services using CY 2011 claims data. 

Of the several areas of diagnostic tests that we examined, we found that billing patterns and PE 

inputs indicated that cardiovascular and ophthalmology diagnostic procedures, respectively, are 

frequently furnished together and that there is some duplication in PE inputs when this occurs. 

For cardiovascular diagnostic services, we reviewed the code pair/combinations with the highest 

utilization in code ranges 75600 through 75893, 78414 through 78496, and 93000 through 
CMS-1590-P 100 

93990. For ophthalmology diagnostic services, we reviewed the code pair/combinations with the 

highest utilization in code ranges 76510 through 76529 and 92002 through 92371. The most 

frequently billed cardiovascular and ophthalmology diagnostic code combinations are listed in 

Tables 14 and 15. 

Under the resource-based PE methodology, specific PE inputs of clinical labor, supplies, 

and equipment are used to calculate PE RVUs for each individual service. When multiple 

diagnostic tests are furnished to the same patient on the same day, most of the clinical labor 

activities and some supplies are not furnished twice. We have identified the following clinical 

labor activities that typically would not be duplicated for subsequent procedures: 

● Greeting and gowning the patient. 

● Preparing the room, equipment and supplies. 

● Education and consent. 

● Completing diagnostic forms. 

● Preparing charts. 

● Taking history. 

● Taking vitals. 

● Preparing and positioning the patient. 

● Cleaning the room. 

● Monitoring the patient. 

● Downloading, filing, identifying and storing photos 

● Developing film. 

● Collating data. 

● QA documentation. 
CMS-1590-P 101 

● Making phone calls. 

● Reviewing prior X-rays, lab and echos. 

We analyzed the CY 2011 claims data for the most frequently billed cardiovascular and 

ophthalmology diagnostic code combinations in order to determine the level of duplication 

present when multiple services are furnished to the same patient on the same day. Our MPPR 

determination excludes the clinical staff minutes associated with the activities that are not 

duplicated for subsequent procedures. For purposes of this analysis, we retained the higher 

number of minutes for each duplicated clinical activity, regardless of the code in the pair with 

which those clinical labor minutes were associated. Equipment time and indirect costs are 

allocated based on clinical labor time; therefore, these inputs were reduced accordingly. While 

we observed that some supplies are duplicated, we did not factor these into our calculations 

because they were low cost and had little impact on our estimate of the level of duplication for 

each code pair. 

When we removed the PE inputs for activities that are not duplicated, and adjusted the 

equipment time and indirect costs, we found support for payment reductions ranging from 8 to 

57 percent for second and subsequent cardiovascular procedures (volume-adjusted average 

reduction across all code pairs of 25 percent); and payment reductions ranging from 9 to 62 

percent for second and subsequent ophthalmology procedures (volume-adjusted average 

reduction across all code pairs of 32 percent). Because we found a relatively wide range of 

reduction by code pair, we believe that an across-the-board reduction of 25 percent for second 

and subsequent procedures (which is approximately the average reduction supported by our 

analysis) would be appropriate. We propose to apply an MPPR to TC-only services and to the 

TC portion of global services for the procedures listed in Tables 12 and 13. The MPPR would 
CMS-1590-P 102 

apply independently to second and subsequent cardiovascular services and to second and 

subsequent ophthalmology services. We propose to make full payment for the TC of the highest 

priced procedure and to make payment at 75 percent (that is, a 25 percent reduction) of the TC 

for each additional procedure furnished by the same physician (or physicians in the same group 

practice, that is, the same group practice NPI) to the same patient on the same day. We are not 

proposing to apply an MPPR to the PC for cardiovascular and ophthalmology services at this 

time. In Table 11, we provide examples illustrating the current and proposed payment amounts: 

TABLE 11: Illustration of Current and Proposed Payments 

Sample Cardiovascular Payment Reduction * 

 Code Code 

Total 

Current 

Total 

Proposed Payment 

 78452 93306 Payment Payment Calculation 

PC $77.00 $65.00 $142.00 $142.00 no reduction 

TC $427.00 $148.00 $575.00 $538.00 $427 + (.75 x $148) 

Global $504.00 $213.00 $717.00 $680.00

$142 + $427 + (.75 x 

$148) 

Sample Ophthalmology Payment Reduction * 

 Code Code 

Total 

Current 

Total 

Proposed Payment 

 92235 92250 Payment Payment Calculation 

PC $46.00 $23.00 $69.00 $69.00 no reduction 

TC $92.00 $53.00 $145.00 $131.75 $92 + (.75 x $53) 

Global $138.00 $76.00 $214.00 $200.75 $69 + $92 + (.75 x $53) 

*Dollar amounts are for illustrative purposes and may not reflect actual payment amounts. 

We believe that the proposed MPPR percentage represents an appropriate reduction for 

the typical delivery of multiple cardiovascular and ophthalmology services on the same day. 

Because the reduction is based on discounting the specific PE inputs that are not duplicated for 

second and subsequent services, the proposal is consistent with our longstanding policy on 

surgical and nuclear medicine diagnostic procedures and advanced imaging procedures which 

applies a 50 percent reduction to second and subsequent procedures, and our more recent policy 
CMS-1590-P 103 

on therapy services, which applies a 20 or 25 percent reduction depending on the setting. 

Furthermore, it is consistent with section 1848(c)(2)(K) of the Act which specifies that 

the Secretary shall identify potentially misvalued codes by examining multiple codes that are 

frequently billed in conjunction with furnishing a single service, and review and make 

appropriate adjustments to their relative values. 

Finally, it is responsive to continued concerns about significant growth in spending on 

imaging and other diagnostic services, and to MedPAC (March 2010) and GAO (July 2009) 

recommendations regarding the expansion of MPPR policies under the PFS to account for 

additional efficiencies. Savings resulting from this proposal would be redistributed to other PFS 

services as required by the general statutory PFS BN provision. In summary, for services 

furnished on or after January 1, 2013, we plan to apply the MPPR to nuclear medicine 

procedures to CPT codes 78306 (Bone imaging; whole body when followed by CPT code 78320 

(Bone imaging; SPECT). We plan to apply the MPPR to the PC and the TC of advanced 

imaging procedures to multiple physicians in the same group practice (same group NPI). 

Therefore, the MPPR will apply when one or more physicians in the same group practice furnish 

services to the same patient, in the same session, on the same day. Finally, we propose to apply 

an MPPR to TC-only services and to the TC portion of global services for diagnostic 

cardiovascular and ophthalmology procedures. The reduction would apply independently to 

cardiovascular and ophthalmology services. We propose to make full payment for the TC of the 

highest priced procedure and payment at 75 percent of the TC for each additional procedure 

furnished by the same physician (or physicians in the same group practice, that is, the same 

group practice NPI) to the same patient on the same day. 

TABLE 12: Diagnostic Cardiovascular Services Subject to the Multiple Procedure 

Payment Reduction
CMS-1590-P 104 

Code Descriptor

75600 Contrast x-ray exam of aorta

75605 Contrast x-ray exam of aorta

75625 Contrast x-ray exam of aorta

75630 X-ray aorta leg arteries

75650 Artery x-rays head & neck

75658 Artery x-rays arm

75660 Artery x-rays head & neck

75662 Artery x-rays head & neck

75665 Artery x-rays head & neck

75671 Artery x-rays head & neck

75676 Artery x-rays neck

75680 Artery x-rays neck

75685 Artery x-rays spine

75705 Artery x-rays spine

75710 Artery x-rays arm/leg

75716 Artery x-rays arms/legs

75726 Artery x-rays abdomen

75731 Artery x-rays adrenal gland

75733 Artery x-rays adrenals

75736 Artery x-rays pelvis

75741 Artery x-rays lung

75743 Artery x-rays lungs

75746 Artery x-rays lung

75756 Artery x-rays chest

75774 Artery x-ray each vessel

75791 Av dialysis shunt imaging

75809 Nonvascular shunt x-ray

75820 Vein x-ray arm/leg

75822 Vein x-ray arms/legs

75825 Vein x-ray trunk

75827 Vein x-ray chest

75831 Vein x-ray kidney

75833 Vein x-ray kidneys

75840 Vein x-ray adrenal gland

75842 Vein x-ray adrenal glands

75860 Vein x-ray neck

75870 Vein x-ray skull

75872 Vein x-ray skull

75880 Vein x-ray eye socket

75885 Vein x-ray liver

75887 Vein x-ray liver

75889 Vein x-ray liver

Code Descriptor

75891 Vein x-ray liver

75893 Venous sampling by catheter

78428 Cardiac shunt imaging

78445 Vascular flow imaging

78451 Ht muscle image spect sing

78452 Ht muscle image spect mult

78453 Ht muscle image planar sing

78454 Ht musc image planar mult

78456 Acute venous thrombus image

78457 Venous thrombosis imaging

78458 Ven thrombosis images bilat

78466 Heart infarct image

78468 Heart infarct image (ef)

78469 Heart infarct image (3D)

78472 Gated heart planar single

78473 Gated heart multiple

78481 Heart first pass single

78483 Heart first pass multiple

78494 Heart image spect

78496 Heart first pass add-on

93005 Electrocardiogram tracing

93017 Cardiovascular stress test

93318 Echo transesophageal intraop

93024 Cardiac drug stress test

93025 Microvolt t-wave assess

93041 Rhythm ecg tracing

93225 Ecg monit/reprt up to 48 hrs

93226 Ecg monit/reprt up to 48 hrs

93229 Remote 30 day ecg tech supp

93270 Remote 30 day ecg rev/report

93271 Ecg/monitoring and analysis

93278 ECG/signal-averaged

93279 Pm device progr eval sngl

93280 Pm device progr eval dual

93281 Pm device progr eval multi

93282 Icd device prog eval 1 sngl

93283 Icd device progr eval dual

93284 Icd device progr eval mult

93285 Ilr device eval progr

93286 Pre-op pm device eval

93287 Pre-op icd device eval

93288 Pm device eval in person
CMS-1590-P 105 

Code Descriptor

93289 Icd device interrogate

93290 Icm device eval

93291 Ilr device interrogate

93292 Wcd device interrogate

93293 Pm phone r-strip device eval

93296 Pm/icd remote tech serv

93303 Echo transthoracic

93304 Echo transthoracic

93306 Tte w/doppler complete

93307 Tte w/o doppler complete

93308 Tte f-up or lmtd

93312 Echo transesophageal

93314 Echo transesophageal

93318 Echo transesophageal intraop

93320 Doppler echo exam heart

93321 Doppler echo exam heart

93325 Doppler color flow add-on

93350 Stress tte only

93351 Stress tte complete

93701 Bioimpedance cv analysis

93724 Analyze pacemaker system

93786 Ambulatory BP recording

93788 Ambulatory BP analysis

93880 Extracranial study

Code Descriptor

93882 Extracranial study

93886 Intracranial study

93888 Intracranial study

93890 Tcd vasoreactivity study

93892 Tcd emboli detect w/o inj

93893 Tcd emboli detect w/inj

93922 Upr/l xtremity art 2 levels

93923 Upr/lxtr art stdy 3+ lvls

93924 Lwr xtr vasc stdy bilat

93925 Lower extremity study

93926 Lower extremity study

93930 Upper extremity study

93931 Upper extremity study

93965 Extremity study

93970 Extremity study

93971 Extremity study

93975 Vascular study

93976 Vascular study

93978 Vascular study

93979 Vascular study

93980 Penile vascular study

93981 Penile vascular study

93990 Doppler flow testing

TABLE 13: Diagnostic Ophthalmology Services Subject to the Multiple Procedure 

Payment Reduction

Code Descriptor

76510 Ophth us b & quant a

76511 Ophth us quant a only

76512 Ophth us b w/non-quant a

76513 Echo exam of eye water bath

76514 Echo exam of eye thickness

76516 Echo exam of eye

76519 Echo exam of eye

92025 Corneal topography

92060 Special eye evaluation

92081 Visual field examination(s)

92082 Visual field examination(s)

92083 Visual field examination(s)

92132 Cmptr ophth dx img ant segmt

92133 Cmptr ophth img optic nerve

Code Descriptor

92134 Cptr ophth dx img post segmt

92136 Ophthalmic biometry

92228 Remote retinal imaging mgmt

92235 Eye exam with photos

92240 Icg angiography

92250 Eye exam with photos

92265 Eye muscle evaluation

92270 Electro-oculography

92275 Electroretinography

92283 Color vision examination

92284 Dark adaptation eye exam

92285 Eye photography

92286 Internal eye photography
CMS-1590-P 106 

TABLE 14: Frequently Billed Diagnostic Cardiovascular Combinations 

Code Range 75600-75893 

Code Descriptor Code Descriptor Code Descriptor Code Descriptor 

75710 Artery x-rays arm/leg 75791 Av dialysis shunt imaging 

75625 Contrast x-ray exam of 

aorta 

75716 Artery x-rays arms/legs 

75625 Contrast x-ray exam of 

aorta 

75716 Artery x-rays arms/legs 75774 Artery x-ray each 

vessel 

 

75820 Vein x-ray arm/leg 75827 Vein x-ray chest 

75625 Contrast x-ray exam of 

aorta 

75710 Artery x-rays arm/leg 

75791 Av dialysis shunt 

imaging 

75827 Vein x-ray chest 

75658 Artery x-rays arm 75791 Av dialysis shunt imaging 75820 Vein x-ray 

arm/leg 

75827 Vein x-ray 

chest 

75710 Artery x-rays arm/leg 75774 Artery x-ray each vessel 

75820 Vein x-ray arm/leg 93931 Upper extremity study 

75791 Av dialysis shunt 

imaging 

75820 Vein x-ray arm/leg 

Code Range 78414-78496 

Code Descriptor Code Descriptor Code Descriptor Code Descriptor 

78452 Ht muscle image spect 

mult 

93306 Tte w/doppler complete 

78452 Ht muscle image spect 

mult 

93017 Cardiovascular stress test 

78452 Ht muscle image spect 

mult 

93306 Tte w/doppler complete 93880 Extracranial 

study 

 

78452TC Ht muscle image spect 

mult 

93017 Cardiovascular stress test 

78452 Ht muscle image spect 

mult 

93880 Extracranial study 

78452TC Ht muscle image spect 

mult 

93306 Tte w/doppler complete 

78452 Ht muscle image spect 

mult 

93017 Cardiovascular stress test 93306 Tte w/doppler 

complete 

 

78451 Ht muscle image spect 

sing 

93306 Tte w/doppler complete 

78452TC Ht muscle image spect 

mult 

93306TC Tte w/doppler complete 

78452 Ht muscle image spect 

mult 

93306 Tte w/doppler complete 93880 Extracranial 

study 

93978 Vascular 

study 

Code Range 93000-93990 

Code Descriptor Code Descriptor Code Descriptor 

93306 Tte w/doppler 

complete 

93880 Extracranial study 

93320 Doppler echo exam 

heart 

93325 Lower extremity study 93351 Stress tte complete 

93922 Upr/l xtremity art 2 

levels 

93925 Lower extremity study 

93923 Upr/lxtr art stdy 3+ 

lvls 

93925 Lower extremity study 

93306TC Tte w/doppler 

complete 

93880TC Extracranial study 
CMS-1590-P 107 

93880 Extracranial study 93978 Vascular study 

93284 Icd device progr eval 

mult 

93290 Icm device eval 

93922 Upr/l xtremity art 2 

levels 

93926 Lower extremity study 

93965 Extremity study 93970 Extremity study 

93925 Lower extremity study 93970 Extremity study 

TABLE 15: Frequently Billed Diagnostic Ophthalmology Combinations 

Code Range 76510-76529 

Code Descriptor Code Descriptor Code Descriptor 

76514 Echo exam of eye thickness 92133 Cmptr ophth img optic 

nerve 

 

76514 Echo exam of eye thickness 92083 Visual field 

examination(s) 

92133 Cmptr ophth img optic 

nerve 

76514 Echo exam of eye thickness 92083 Visual field 

examination(s) 

 

76514 Echo exam of eye thickness 92250 Eye exam with photos 

76514 Echo exam of eye thickness 92083 Visual field 

examination(s) 

92250 Eye exam with photos 

76512 Ophth us b w/non-quant a 92134 Cptr ophth dx img post 

segmt 

 

76512 Ophth us b w/non-quant a 92250 Eye exam with photos 

76514 Echo exam of eye thickness 92286 Internal eye photography 

76514 Echo exam of eye thickness 92134 Cptr ophth dx img post 

segmt 

 

76512 Ophth us b w/non-quant a 92235 Eye exam with photos 92250 Eye exam with photos 

Code Range 92002-92371 

Code Descriptor Code Descriptor Code Descriptor 

92083 Visual field examination(s) 92133 Cmptr ophth img optic 

nerve 

 

92235 Eye exam with photos 92250 Eye exam with photos 

92083 Visual field examination(s) 92250 Eye exam with photos 

92083 Visual field examination(s) 92134 Cptr ophth dx img post 

segmt 

 

92134 Cptr ophth dx img post 

segmt 

92235 Eye exam with photos 

92134 Cptr ophth dx img post 

segmt 

92250 Eye exam with photos 

92134 Cptr ophth dx img post 

segmt 

92235 Eye exam with photos 92250 Eye exam with photos 

92250 Eye exam with photos 92285 Eye photography 

92082 Visual field examination(s) 92250 Eye exam with photos 

92081 Visual field examination(s) 92285 Eye photography 
CMS-1590-P 108 

C. Malpractice RVUs

Section 1848(c) of the Act requires that each service paid under the PFS be comprised of 

three components: work; PE; and malpractice. From 1992 to 1999, malpractice RVUs were 

charge-based, using weighted specialty-specific malpractice expense percentages and 1991 

average allowed charges. Malpractice RVUs for new codes after 1991 were extrapolated from 

similar existing codes or as a percentage of the corresponding work RVU. Section 4505(f) of the 

BBA, which amended section 1848(c) of the Act, required us to implement resource-based 

malpractice RVUs for services furnished beginning in 2000. Therefore, initial implementation of 

resource-based malpractice RVUs occurred in 2000. 

The statute also requires that we review and, if necessary, adjust RVUs no less often than 

every 5 years. The first review and update of resource-based malpractice RVUs was addressed 

in the CY 2005 PFS final rule with comment period (69 FR 66263). Minor modifications to the 

methodology were addressed in the CY 2006 PFS final rule with comment period 

(70 FR 70153). In the CY 2010 PFS final rule with comment period, we implemented the 

second review and update of malpractice RVUs. For a discussion of the second review and 

update of malpractice RVUs, see the CY 2010 PFS proposed rule (74 FR 33537) and final rule 

with comment period (74 FR 61758). 

As explained in the CY 2011 PFS final rule with comment period (75 FR 73208), 

malpractice RVUs for new and revised codes effective before the next Five-Year Review of 

Malpractice (for example, effective CY 2011 through CY 2014, assuming that the next review of 

malpractice RVUs occurs for CY 2015) are determined either by a direct crosswalk to a similar 

source code or by a modified crosswalk to account for differences in work RVUs between the 

new/revised code and the source code. For the modified crosswalk approach, we adjust (or 

‘‘scale’’) the malpractice RVU for the new/revised code to reflect the difference in work RVU 
CMS-1590-P 109 

between the source code and the new/revised work value (or, if greater, the clinical labor portion 

of the fully implemented PE RVU) for the new code. For example, if the proposed work RVU 

for a revised code is 10 percent higher than the work RVU for its source code, the malpractice 

RVU for the revised code would be increased by 10 percent over the source code malpractice 

RVU. This approach presumes the same risk factor for the new/revised code and source code 

but uses the work RVU for the new/revised code to adjust for risk-of-service. 

For CY 2013, we will continue our current approach for determining malpractice RVUs 

for new/revised codes. We will publish a list of new/revised codes and the malpractice 

crosswalk(s) used for determining their malpractice RVUs in the final rule with comment period. 

The CY 2013 malpractice RVUs for new/revised codes will be implemented as interim final 

values in the CY 2013 PFS final rule with comment period, where they will be subject to public 

comment. They will then be finalized in the CY 2014 PFS final rule with comment period. 
CMS-1590-P 110 

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 resource cost differences among localities compared to the 

national average for each of the three fee schedule components (that is, work, practice expense 

(PE), and malpractice (MP)). While requiring 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 beginning January 1, 2011. 

Section 1848 (e)(1)(E) of the Act provides for a 1.0 floor for the work GPCIs, which was 

set to expire at the end of 2011. The statute was amended to extend the 1.0 floor for the work 

GPCIs through February 29, 2012 by section 303 of the Temporary Payroll Tax Cut 

Continuation Act of 2011 (TPTCCA) (Pub. L. 112-78). The statute was again amended by 

section 3004 of the Middle Class Tax Relief and Job Creation Act of 2012 (MCTRJCA) (P.L. 

112-399) to extend the 1.0 work floor for GPCIs throughout the remainder of CY 2012 (that is, 

for services furnished no later than December 31, 2012). During the development of the CY 

2012 PFS final rule with comment period, neither TPTCCA nor MCTRJCA had been enacted 

and, because the work GPCI floor was set to expire at the end of 2011, the GPCIs published in 

Addendum E of the CY 2012 PFS final rule with comment period did not reflect the 1.0 work 

floor. Appropriate changes to the CY 2012 GPCIs were made to reflect the 1.0 work floor 

required by section 303 of the TPTCCA and section 3004 of the MCTRJCA. 

Since the 1.0 work GPCI floor provided in section 1848 (e)(1)(E) of the Act is set to 
CMS-1590-P 111 

expire prior to the implementation of the CY 2013 PFS, the proposed CY 2013 work GPCIs and 

summarized geographic adjustment factors (GAFs) published in addendums D and E of this 

CY 2013 PFS proposed rule do not reflect the 1.0 work GPCI floor for CY 2013. As required by 

section 1848 (e)(1)(G) and section1848 (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 applicable in CY 2013. 

 In the CY 2012 PFS final rule with comment period we made several refinements to 

the GPCIs (76 FR 73081 through 73092), including revising the sixth GPCI update to reflect the 

most recent data, with modifications. Specifically, we finalized our proposal to change the GPCI 

cost share weights for CY 2012 to reflect the most recent rebased and revised Medicare 

Economic Index (MEI). As a result, the cost share weight for the work GPCI (as a percentage of 

the total) was updated from 52.466 percent to 48.266 percent, and the cost share weight for the 

PE GPCI was revised from 43.669 percent to 47.439 percent with a change in the employee 

compensation component from 18.654 to 19.153 percentage points. The cost share weight for 

the office rent component of the PE GPCI was changed from 12.209 percent to 10.223 

percentage points (fixed capital with utilities), and the medical equipment, supplies, and other 

miscellaneous expenses component was updated to 9.968 percentage points. In addition, we 

finalized the weight for purchased services at 8.095 percentage points, of which 5.011 percentage 

points are adjusted for geographic cost differences. Lastly, the cost share weight for the MP 

GPCI was revised from 3.865 percent to 4.295 percent. Table 16 displays the cost share weights 

that were finalized in the CY 2012 final rule with comment period. Note that the employee 

compensation; office rent; purchased services; and equipment supplies and other cost share 

weights sum to the total PE GPCI cost share weights of 47.439 percent. 
CMS-1590-P 112 

TABLE 16: Cost Share Weights finalized in CY 2012 GPCI Update 

Expense Category Cost Share 

Weights % 

Physician Work 48.266 

Practice Expense 47.439 

 Employee Compensation 19.153 

 Office Rent 10.223 

 Purchased Services 8.095

 Equipment, Supplies, and Other 9.968

Malpractice Insurance 4.295

 We also finalized several other policies including the use of 2006 through 2008 

American Community Survey (ACS) two-bedroom rental data as a proxy for the relative cost 

difference in physician office rent. In addition, we created a purchased services index to account 

for labor-related services within the ''all other services'' and ''other professional expenses'' MEI 

components. In response to public commenters who recommended that we utilize Bureau of 

Labor Statistics (BLS) Occupational Employment Statistics (OES) data to capture the “full 

range” of occupations included in the offices of physician industry to calculate the nonphysician 

employee wage component (also referred to as the employee wage index) of the PE GPCI, we 

finalized a policy of using 100 percent of the total wage share of nonphysician occupations in the 

offices of physicians' industry to calculate the nonphysician employee wage component of the 

PE GPCI. 

2. Recommendations from the Institute of Medicine 

 Concurrent with our CY 2012 rulemaking cycle, the Institute of Medicine released the 

final version of its first of two anticipated reports entitled “Geographic Adjustment in Medicare 

Payment: Phase I: Improving Accuracy, Second Edition” on September 28, 2011. This report 

included an evaluation of the accuracy of geographic adjustment factors for the hospital wage 

index and the GPCIs, as well as the methodology and data used to calculate them. Several of the 

policies that we finalized in CY 2012 rulemaking addressed several of the recommendations 
CMS-1590-P 113 

contained in the Institute of Medicine’s first report. Because we did not have adequate time to 

completely address the Institute of Medicine’s Phase I report recommendations during CY 2012 

rulemaking, we have included a discussion in this proposed rule about the recommendations that 

were not implemented or discussed in the CY 2012 final rule with comment period. We look 

forward to receiving comments on these recommendations. 

 The Institute of Medicine’s second report, expected in summer 2012, will evaluate the effects 

of geographic adjustment factors (hospital wage index and GPCIs) on the distribution of the 

healthcare workforce, quality of care, population health, and the ability to provide efficient, high 

value care. We did not receive the Institute of Medicine’s Phase II report in time for consideration 

for this CY 2013 proposed rule. We intend to address the Institute of Medicine’s recommendations 

in the Phase II report once we have had an opportunity to fully evaluate the report and its 

recommendations. 

3. GPCI Discussion for CY 2013 

 CY 2013 is the final year of the sixth GPCI update and, because we will propose updates 

next year, we are not including any proposals related to the GPCIs in this proposed rule. In 

response to public inquiries about exceptions to the calculated GPCIs, we are providing a brief 

discussion about the permanent 1.0 PE floor for frontier States, the 1.5 work floor for Alaska, the 

GPCIs for the Puerto Rico payment locality, and the expiration of the GPCI 1.0 work floor 

required under section 1848 (e)(1)(E) of the Act. We also discuss recommendations from the 

first Institute of Medicine report that were not addressed during CY 2012 rulemaking in this 

proposed rule. 

a. Alaska Work Floor and PE GPCI Floor for Frontier States 

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. Therefore, the 1.5 work floor for Alaska will 
CMS-1590-P 114 

remain in effect in CY 2013. In addition, section 1848(e) (1)(I) of the Act establishes a 1.0 PE 

GPCI floor for physicians' services furnished in frontier States effective January 1, 2011. In 

accordance with section 1848(e)(1)(I) of the Act, beginning in CY 2011, we applied a 1.0 PE 

GPCI floor for physicians' services furnished in States determined to be frontier States. There 

are no proposed changes to those States identified as “Frontier States” for the CY 2013 proposed 

rule. The following States are considered to be “Frontier States” for CY 2013: Montana, North 

Dakota, Nevada, South Dakota, and Wyoming. 

b. GPCI Assignments for the Puerto Rico Payment Locality 

 Recently, we have received inquiries from representatives of the Puerto Rico medical 

community regarding our policies for determining the GPCIs for the Puerto Rico payment 

locality. While we are not making any proposals related to the GPCIs for Puerto Rico, in 

response to those inquiries, we are providing the following discussion regarding the GPCIs 

assigned to the Puerto Rico payment locality. We anticipate recalculating all the GPCI’s in the 

seventh GPCI update currently anticipated in CY 2014. 

As noted above, we are required by section 1848(e)(1)(A) of the Act to develop 

separate GPCIs to measure relative resource cost differences among localities compared to the 

national average for each of the three fee schedule components: work, PE and malpractice 

expense. To calculate these GPCI values, we rely on three primary data sources. We currently 

use the 2006-2008 BLS OES data to calculate the work GPCI, the nonphysician employee wage 

component of PE GPCI, and the labor costs associated with the purchased services component of 

PE GPCI. We use 2006-2008 ACS data to calculate the office rent component of the PE GPCI. 

Finally, we use 2006-2007 malpractice premium data to calculate the MP GPCI. For all 

localities, including Puerto Rico, we assume equipment, supplies, and other expenses are 

purchased in a national market and that the costs do not vary by geographic location. Therefore, 
CMS-1590-P 115 

we do not use data on the price of equipment, supplies, and expenses across localities in 

calculating PE GPCIs. With the exception of the MP GPCI, we have current data from the 

applicable sources allowing us to calculate the work and PE GPCIs for the Puerto Rico payment 

locality. The 2006-2008 BLS OES data and rental values derived from the 2006-2008 ACS 

indicate that the costs associated with operating a physician practice in Puerto Rico are the 

lowest among all payment localities. 

 In order to calculate the MP GPCI for the various Medicare PFS localities, we collect 

malpractice insurance market share and premium data from state departments of insurance and 

from state rate filings. As discussed in our contractor’s report (Final Report on the Sixth Update 

of the Geographic Practice Cost Index for the Medicare Physician Fee Schedule pg. 41), for the 

fourth, fifth, and sixth GPCI updates we were not able to collect this data for the Puerto Rico 

payment locality. Therefore, we carried over the MP GPCI value of 0.249 from previous GPCI 

updates when malpractice premium data were last available. It is important that we have a 

source for more current malpractice premium data for Puerto Rico for use in the upcoming 

seventh GPCI update. We are working with the relevant officials in Puerto Rico to acquire these 

data for use in future rulemaking. We would encourage comments from stakeholders regarding 

potential data sources that may be available for calculating the Puerto Rico malpractice GPCI. 

For a detailed discussion regarding the methodology used to calculate the various components of 

the Puerto Rico GPCIs, we refer readers to our contractor’s report from November of 2010 

entitled “Final Report on the Sixth Update of the Geographic Practice Cost Index for the 

Medicare Physician Fee Schedule” available on our Website at 

http://www.cms.gov/PhysicianFeeSched/downloads/GPCI_Report.pdf. 

c. Expiration of GPCI Work Floor 

The work GPCIs are designed to capture the relative costs of physician labor by Medicare 
CMS-1590-P 116 

PFS locality. Previously, the work GPCIs were developed using the median hourly earnings 

from the 2000 Census of workers in seven professional specialty occupation categories which we 

used as a proxy for physicians’ wages. Physicians’ wages are not included in the occupation 

categories because Medicare payments are a key determinant of physicians’ earnings. That is, 

including physicians' wages in the work GPCIs would effectively make the indices dependent 

upon Medicare payments. As required by law, the work GPCI reflects one quarter of the relative 

wage differences for each locality compared to the national average. The work GPCI updates in 

CYs 2001, 2003, 2005, and 2008 were based on professional earnings data from the 2000 

Census. For the sixth GPCI update in CY 2011, we used the 2006 through 2008 BLS OES data 

as a replacement for the 2000 Census data. 

Although we are not proposing any changes to the data or methodology used to calculate 

the work GPCI for CY 2013, we note that addenda D and E will reflect the expiration of the 

statutory 1.0 work GPCI floor. As noted above, section 1848 (e)(1)(E) of the Act provides for a 

1.0 floor for the work GPCIs, which was set to expire at the end of 2011 until it was temporarily 

extended through February 29, 2012 by section 303 of the TPTCCA. The GPCI work floor was 

extended throughout the remainder of CY 2012 by section 3004 of the MCTRJCA. 

4. Institute of Medicine Phase I Report 

a. Background 

 At our request, the Institute of Medicine is conducting a study of the geographic 

adjustment factors in Medicare payment. It is a comprehensive empirical study of the 

geographic adjustment factors established under sections 1848(e) (GPCI) and 1886(d)(3)(E) of 

the Act (hospital wage index). These adjustments are designed to ensure Medicare payment fees 

and rates reflect differences in input costs across geographic areas. The factors the Institute of 

Medicine is evaluating include the following: 
CMS-1590-P 117 

● Accuracy of the adjustment factors; 

● Methodology used to determine the adjustment factors; and 

● Sources of data and the degree to which such data are representative. 

 Within the context of the U.S. healthcare marketplace, the Institute of Medicine is also 

evaluating and considering the— 

● Effect of the adjustment factors on the level and distribution of the health care 

workforce and resources, including— 

++ Recruitment and retention taking into account mobility between urban and rural areas; 

++ Ability of hospitals and other facilities to maintain an adequate and skilled workforce; 

and 

++ Patient access to providers and needed medical technologies; 

● Effect of adjustment factors on population health and quality of care; and 

● Effect of the adjustment factors on the ability of providers to furnish efficient, high 

value care. 

 The Institute of Medicine’s first report entitled “Geographic Adjustment in Medicare 

Payment, Phase I: Improving Accuracy” evaluated the accuracy of geographic adjustment factors 

and the methodology and data used to calculate them. The recommendations included in the 

Institute of Medicine’s Phase I report that relate to or would have an effect on the methodologies 

used to calculate the GPCIs and the configuration of Medicare PFS payment locality structure are 

summarized as follows: 

● Recommendation 2-1: The same labor market definition should be used for both the 

hospital wage index and the physician geographic adjustment factor. Metropolitan statistical 

areas and statewide non-metropolitan statistical areas should serve as the basis for defining these 

labor markets. 
CMS-1590-P 118 

● Recommendation 2-2: The data used to construct the hospital wage index and the 

physician geographic adjustment factor should come from all health care employers. 

● Recommendation 5-1: The GPCI cost share weights for adjusting fee-for-service 

payments to practitioners should continue to be national, including the three GPCIs (work, PE, and 

liability insurance) and the categories within the PE (office rent and personnel). 

● Recommendation 5-2: Proxies should continue to be used to measure geographic 

variation in the physician work adjustment, but CMS should determine whether the seven proxies 

currently in use should be modified. 

● Recommendation 5-3: CMS should consider an alternative method for setting the 

percentage of the work adjustment based on a systematic empirical process. 

● Recommendation 5-4: The PE GPCI should be constructed with the full range of 

occupations employed in physicians' offices, each with a fixed national weight based on the hours of 

each occupation employed in physicians' offices nationwide. 

● Recommendation 5-5 CMS and the Bureau of Labor Statistics should develop an 

agreement allowing the Bureau of Labor Statistics to analyze confidential data for the Centers for 

Medicare & and Medicaid Services. 

● Recommendation 5-6: A new source of information should be developed to determine the 

variation in the price of commercial office rent per square foot. 

● Recommendation 5-7: Nonclinical labor-related expenses currently included under PE 

office expenses should be geographically adjusted as part of the wage component of the PE. 

This report can be accessed on the Institute of Medicine 's Website at 

http://www.iom.edu/Reports/2011/Geographic-Adjustment-in-Medicare-Payment-Phase-I-Improvin

g-Accuracy.aspx. 

 As previously noted, the Institute of Medicine will consider the role of Medicare 
CMS-1590-P 119 

payments on matters such as the distribution of the healthcare workforce, population health, and 

the ability of providers to produce high-value, high-quality health care in its final report 

anticipated in summer 2012. We were not able to evaluate the recommendations contained in the 

Institute of Medicine’s Phase II report, in time for discussion in this proposed rule. 

b. Institute of Medicine Recommendations Implemented in CY 2012 

 In the CY 2012 final rule with comment period, we addressed three of the 

recommendations offered by the Institute of Medicine in their Phase I report. Specifically, the 

final CY 2012 GPCIs utilized the full range of non-physician occupations in the employee wage 

calculation consistent with Institute of Medicine recommendation 5-4. Additionally, we created 

a new purchased service index to account for non-clinical labor related expenses similar to 

Institute of Medicine recommendation 5-7. Lastly, we have consistently used national cost share 

weights to determine the appropriate weight attributed to each GPCI component, which is 

supported by Institute of Medicine recommendation 5-1 (76 FR 73081 through 73092). In order 

to facilitate a public discussion regarding the Institute of Medicine’s remaining 

recommendations, we are providing a summary analysis of these recommendations in this 

proposed rule below. We will provide our technical analyses of the remaining Institute of 

Medicine Phase I recommendations in a report that will be released on the PFS Website at 

http://www.cms.gov/PhysicianFeeSched. Since we have not yet had an opportunity to review 

the recommendations in the Institute of Medicine’s Phase II report, these analyses focus 

exclusively on the recommendations as presented in the Institute of Medicine’s Phase I release. 

c. Discussion of Remaining Institute of Medicine recommendations 

(1) Institute of Medicine Recommendation Summaries 

(A) Institute of Medicine recommendation 2-1: The same labor market definition should be 

used for both the hospital wage index and the physician geographic adjustment factor. 
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Metropolitan statistical areas and statewide non-metropolitan statistical areas should serve as the 

basis for defining these labor markets. (Geographic Adjustment in Medicare Payment, Phase I: 

Improving Accuracy pages 2-1 thru 2-29) 

(i) Locality Background 

The current PFS locality structure was developed and implemented in 1997. There are 

currently 89 total PFS localities; 34 localities are Statewide areas (that is, only one locality for 

the entire State). There are 52 localities in the other 16 States, with 10 States having 2 localities, 

2 States having 3 localities, 1 State having 4 localities, and 3 States having 5 or more localities. 

The District of Columbia, Maryland, and Virginia suburbs, Puerto Rico, and the Virgin Islands 

are additional localities that make up the remainder of the total of 89 localities. The 

development of the current locality structure is described in detail in the CY 1997 PFS proposed 

rule (61 FR 34615) and the subsequent final rule with comment period (61 FR 59494). 

 Prior to 1992, Medicare payments for physicians’ services were made under the 

reasonable charge system. Payments were based on the charging patterns of physicians. This 

resulted in large differences among types of services, geographic payment areas, and physician 

specialties. Recognizing this, the Congress replaced the reasonable charge system with the 

Medicare PFS in the Omnibus Budget Reconciliation Act (OBRA) of 1989, effective January 1, 

1992. Payments under the fee schedule are based on the relative resources required to provide 

services and vary among areas as resource costs vary geographically as measured by the GPCIs. 

 Payment localities were established under the reasonable charge system by local 

Medicare carriers based on their knowledge of local physician charging patterns and economic 

conditions. These localities changed little between the inception of Medicare in 1967 and the 

beginning of the PFS. As a result, a study was begun in 1994 which resulted in a comprehensive 

locality revision, which was implemented in 1997 (61 FR 59494). 
CMS-1590-P 121 

 The revised locality structure reduced the number of localities from 210 to the current 89 

and the number of statewide localities increased from 22 to 34. The revised localities were based 

on locality resource cost differences as reflected by the GPCIs. A full discussion of the 

methodology can be found in the CY 1997 PFS final rule with comment period (61 FR 59494). 

The current 89 fee schedule areas are defined alternatively by state boundaries (for example, 

Wisconsin), metropolitan areas (for example, Metropolitan St. Louis, MO), portions of a 

metropolitan area (for example, Manhattan), or rest-of-state areas that exclude metropolitan areas 

(for example, Rest of Missouri). This locality configuration is used to calculate the GPCIs that 

are in turn used to calculate payments for physicians’ services under the PFS. 

 As was stated in the CY 2011 final rule with comment period (75 FR 73261), we 

currently require that changes to the PFS locality structure be done in a budget neutral manner 

within a state. For many years, we have sought consensus for any locality changes among the 

professionals whose payments would be affected. We have also considered more comprehensive 

changes to locality configurations. In 2008, we issued a draft comprehensive report detailing 

four different locality configuration options 

(http://www.cms.gov/physicianfeesched/downloads/ReviewOfAltGPCIs.pdf). The alternative locality 

configurations in the report are described below. 

● Option 1: CMS Core-Based Statistical Area (CBSA) Payment Locality Configuration: 

CBSAs are a combination of Office of Management and Budget (OMB’s) Metropolitan 

Statistical Areas (MSAs) and their Micropolitan Statistical Areas. Under this option, MSAs 

would be considered as urban CBSAs. Micropolitan Statistical Areas (as defined by OMB) and 

rural areas would be considered as non-urban (rest of State) CBSAs. This approach would be 

consistent with the areas used in the Inpatient Prospective Payment System (IPPS) prereclassification wage index, which is the hospital wage index for a geographic area (CBSA or 
CMS-1590-P 122 

non-CBSA) calculated from submitted hospital cost report data before statutory adjustments 

reconfigure, or “reclassify” a hospital to an area other than its geographic location, to adjust 

payments for difference in local resource costs in other Medicare payment systems. Based on 

data used in the 2008 locality report, this option would increase the number of PFS localities 

from 89 to 439. 

● Option 2: Separate High-Cost Counties from Existing Localities (Separate Counties): 

Under this approach, higher cost counties are removed from their existing locality structure, and 

they would each be placed into their own locality. This option would increase the number of 

PFS localities from 89 to 214, using a 5 percent GAF differential to separate high-cost counties. 

● Option 3: Separate MSAs from Statewide Localities (Separate MSAs): This option 

begins with statewide localities and creates separate localities for higher cost MSAs (rather than 

removing higher cost counties from their existing locality as described in Option 2). This option 

would increase the number of PFS localities from 89 to 130, using a 5 percent GAF differential 

to separate high-cost MSAs. 

● Option 4: Group Counties Within a State Into Locality Tiers Based on Costs 

(Statewide Tiers): This option creates tiers of counties (within each State) that may or may not 

be contiguous but share similar practice costs. This option would increase the number of PFS 

localities from 89 to 140, using a 5 percent GAF differential to group similar counties into 

statewide tiers. 

 For a detailed discussion of the public comments on the contractor's 2008 draft report 

detailing four different locality configurations, we refer readers to the CY 2010 PFS proposed 

rule (74 FR 33534) and subsequent final rule with comment period (74 FR 61757). There was 

no public consensus on the options, although a number of commenters expressed support for 

Option 3 (separate MSAs from Statewide localities) because the commenters believed this 
CMS-1590-P 123 

alternative would improve payment accuracy and could mitigate potential reductions to rural 

areas compared to Option 1 (CMS CBSAs). 

 In response to some public comments regarding the third of the four locality options, we 

had our contractor conduct an analysis of the impacts that would result from the application of 

Option 3. Those results were displayed in the final locality report released in 2011. The final 

report, entitled “Review of Alternative GPCI Payment Locality Structures – Final Report,” is 

accessible from the CMS PFS Web page under the heading “Review of Alternative GPCI 

Payment Locality Structures – Final Report.” The report may also be accessed directly from the 

following link: 

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

eview.pdf 

(ii) Institute of Medicine Recommendation Discussion 

 The Institute of Medicine recommends altering the current locality structure that was 

originally based on areas set by local contractors and, in 1996, reduced from 210 to current 89 

using a systematic iterative methodology. Rather than using the current uniform fee schedule 

areas in adjusting for relative cost differences as compared to the national average, the Institute 

of Medicine recommends a three-tiered system for defining fee schedule areas. In the first tier, 

the Institute of Medicine proposes applying county-based fee schedule areas to calculate the 

employee wage component of the PE GPCI. Although the Institute of Medicine’s report states 

that it recommends that “Metropolitan statistical areas and statewide non-metropolitan statistical 

areas should serve as the basis for defining these labor markets,” the Institute of Medicine also 

recommends applying an out-commuting adjustment, which would permit employee wage index 

values to vary by county. Since the employee wage index is one component of the PE GPCI, 

these values also would vary by county under the Institute of Medicine’s proposal. 
CMS-1590-P 124 

 To understand why the employee wage index would vary by county under the Institute of 

Medicine’s recommendation, consider the three steps that would be required to calculate the 

employee wage index. The first step calculates the average hourly wage (AHW) for workers 

employed in each MSA or residual (rest of state) area. The wages of workers in each occupation 

are weighted by the number of workers employed in physicians’ offices nationally. The second 

step applies a commuting-based smoothing adjustment to create area index wages for each 

county. The commuting-adjusted county index wages are equal to a weighted average of the 

AHW values calculated in the first step, where the weights are county-to-MSA out-commuting 

patterns. The Institute of Medicine’s out-commuting-based weights equal the share of health 

care workers that live in a county where a physician’s office is located who commute out of the 

county to work in a physician office in each MSA. The third step sets each physician’s employee 

index wage equal to the estimated area index wage (calculated in Step 2) of the county in which 

the physician office is located. Because the out-commuting adjustment envisioned by the 

Institute of Medicine in the second step varies by county, the employee wage index value—and 

thus the PE GPCI as a whole— would also potentially vary by county depending on the 

smoothing option chosen. If implemented, the number of employee wage index payment areas 

could potentially increase from 89 to over 3,000. 

 The Institute of Medicine’s second tier of fee schedule areas would use an MSA-based 

approach. The Institute of Medicine proposes using the MSA-based system for the work GPCI, 

the office rent index, the purchased services index, and the MP GPCI. An MSA is made up of 

one or more counties, including the counties that contain the core urban area with a population of 

50,000 or more, as well as surrounding counties that exhibit a high degree of social and 

economic integration (as measured by commuting patterns) with the urban core. MSAs are 

designed to be socially and economically integrated units based on the share of workers who 
CMS-1590-P 125 

commute to work within the urban core of each MSA. Implementing an MSA-based locality 

structure would expand the number of fee schedule areas from 89 to upwards of 400 plus 

additional MSAs for U.S. territories (for example, Virgin Islands, American Samoa, Guam, 

Northern Marianna Islands). 

 In its third payment area tier, the Institute of Medicine proposes creating a national 

payment area for the “equipment, supplies and other” index. We currently do not adjust PEs 

associated with supplies and equipment since we believe they are typically purchased in a 

national market. Thus, this approach is equivalent to using a national fee schedule area to define 

this index. The Institute of Medicine proposes no change to the fee schedule area used to 

compute the “equipment, supplies and other” index. 

 Based on our contractor’s analysis, there would be significant redistributive impacts if we 

were to implement a policy that would reconfigure the PFS localities based on the Institute of 

Medicine’s three-tiered recommendation. Many rural areas would see substantial decreases in 

their corresponding GAF and GPCI values as higher cost counties are removed from current 

“Rest of State” payment areas. Conversely, many urban areas, especially those areas that are 

currently designated as “Rest of State” but reside within higher cost MSAs, would experience 

increases in their applicable GPCIs and GAFs. 

 The localities used to calculate the GPCIs have been a subject of substantial discussion 

and debate since the implementation of the PFS. The intensity of those discussions has increased 

since the last comprehensive update to the locality structure in 1997. Physicians and other 

suppliers in areas such as Santa Cruz County, California and Prince William County, Virginia 

have expressed concern that the current locality structure does not appropriately capture 

economic and demographic shifts that have taken place since the last PFS locality update. On 

the other hand, rural practitioners have argued that revisions to the current PFS payment 
CMS-1590-P 126 

localities will reduce their payments and exacerbate the problems of attracting physicians and 

other practitioners to rural areas. In the past, we have also heard concerns from representatives 

of some statewide localities regarding the potential implications of adopting an alternative 

locality structure that would change their current statewide payment area (74 FR 33536). 

 The Institute of Medicine stated in its Phase I report regarding its locality 

recommendation that, “While the payment areas would stay the same for the HWI (hospital wage 

index), implementing this recommendation would mean that the GPCI payment areas would 

expand from 89 to 441 areas, which would be a significant change. The impact of the change in 

payment areas will be assessed in the Phase II report.” (“Geographic Adjustment in Medicare 

Payment: Phase I: Improving Accuracy, Second Edition” on September 28, 2011 pg 5-6.) 

Moreover, the Institute of Medicine’s Phase II report will evaluate the effects of geographic 

adjustment factors on the distribution of the healthcare workforce, quality of care, population 

health, and the ability to provide efficient, high value care. Over the years, commenters that 

have opposed revisions to localities have claimed that changes to the PFS areas could have a 

significant impact on the ability of rural areas to attract physicians. Certainly, one of our major 

goals when we last comprehensively revised the Medicare PFS localities in 1996 was to avoid 

excessively large urban/rural payment differences (61 FR 59494). In 1996, we were hopeful that 

the revisions would improve access to care for rural areas (61 FR 59494). Some areas may have 

experienced both economic and demographic shifts since the last comprehensive locality update. 

Before moving forward with the Institute of Medicine’s three tiered locality recommendation, or 

any other potential locality revision, we need to assess, and prepare to inform the public of, the 

impact of any change for all Medicare stakeholders. The Institute of Medicine’s Phase II report, 

scheduled for release this summer 2012, should contain an evaluation of many of these important 

factors including: 
CMS-1590-P 127 

● The effect of the adjustment factors on the level and distribution of the health care 

workforce and resources, including-- 

++ Recruitment and retention taking into account mobility between urban and rural 

areas; 

++ Ability for hospitals and other facilities to maintain an adequate and skilled 

workforce; 

++ Patient access to providers and needed medical technologies; 

++ Effect of adjustment factors on population health and quality of care; and 

++ Effect of adjustment factors on the ability of providers to furnish efficient, high value 

care. 

To fully assess the broader public policy implications associated with the Institute of 

Medicine’s locality recommendation, we must first fully assess and analyze the 

recommendations contained in the Institute of Medicine’s phase II report. Accordingly, we 

believe that it would be premature to propose any change to the PFS localities at this time. 

 In conjunction with a specific proposal for changing the locality configuration during 

future rulemaking, we would provide detailed analysis on the impact of the changes for 

physicians in each county. We would also provide opportunities for public input (for example, 

Town Hall meetings or Open Door Forums), as well as opportunities for public comments 

afforded by the rulemaking process. 

 While we are making no proposal in this proposed rule to change the current locality 

configuration, we are seeking public comment regarding Institute of Medicine’s recommended 

three-tiered PFS payment locality definition. In addition, we will make our technical analyses of 

the Institute of Medicine locality recommendations, specific to the Phase I report, available on 

the PFS Website at http://www.cms.gov/PhysicianFeeSched/. 
CMS-1590-P 128 

(B) Institute of Medicine Recommendation 2-2: The data used to construct the hospital wage 

index and the physician geographic adjustment factor should come from all healthcare employers 

(Geographic Adjustment in Medicare Payment, Phase I: Improving Accuracy pages 2-1 thru 2-

29) and; Recommendation 5-5 CMS and the Bureau of Labor Statistics should develop an 

agreement allowing the Bureau of Labor Statistics to analyze confidential data for the Centers for 

Medicare and Medicaid Services. (Geographic Adjustment in Medicare Payment, Phase I: 

Improving Accuracy pg 5-38.) 

 The Institute of Medicine recommends altering the data used to calculate the employee 

wage index. Specifically, Institute of Medicine recommends using wage data for workers in the 

healthcare industry rather than wage data for workers across all-industries. Although all-industry 

wage data has the largest sample size, the Institute of Medicine “...is concerned that the [allindustry] sample does not represent physician offices.” BLS OES occupation wage data by 

MSA, however, are not publicly available for the healthcare industry. Using healthcare-industry 

wages requires the use of confidential BLS OES data, to which CMS does not have access at this 

time. Although the Institute of Medicine recommends that CMS secure an agreement with BLS 

to use the confidential wage data, the current employee wage index relies on publicly-available 

all-industry wage data. We seek comment on the use of confidential employee wage index data 

rather than the publicly available all-industry wage data. 

 Regardless of whether healthcare-industry or all-industry wage data is used, the Institute 

of Medicine recommends following the current approach adopted by CMS in CY 2012 for 

calculating the employee wage index. This approach constructs the employee wage index as a 

weighted average of occupation wages for the full-range of occupations employed in physicians’ 

offices, where the weights are equal to the fixed national weight based on the hours of each 

occupation employed in physicians’ offices nationwide. We adopted this approach for 
CMS-1590-P 129 

calculating the GPCI employee wage index in the CY 2012 PFS final rule with comment period 

(76 FR 73088). 

(C) Institute of Medicine recommendation 5-2: Proxies should continue to be used to 

measure geographic variation in the physician work adjustment, but CMS should determine 

whether the seven proxies currently in use should be modified (Geographic Adjustment in 

Medicare Payment, Phase I: Improving Accuracy pg 5-36) and; Recommendation 5-3: CMS 

should consider an alternative method for setting the percentage of the work adjustment based on 

a systematic empirical process. (Geographic Adjustment in Medicare Payment, Phase I: 

Improving Accuracy pages 5-36 thru 5-37) 

 The Institute of Medicine recommends replacing the current work GPCI methodology 

with a regression-based approach. We currently use three steps to calculate the work GPCI. 

These steps include: 

(1) Selecting the proxy occupations and calculating an occupation-specific index for 

each proxy; 

(2) Assigning weights to each proxy-occupation index based on the each occupation’s 

share of total national wages to create an aggregate proxy-occupation index; and 

(3) Adjusting the aggregate proxy-occupation index by a physician inclusion factor to 

calculate the final work GPCI. 

 By using this approach, the current methodology reduces the circularity problem that 

occurs when work GPCI values are based on direct measurements of physician earnings. 

Because physician earnings are made up of both wages and a return on investment from 

ownership of the physician practice, calculating the work GPCI using physician earnings 

information would assign areas where physician practices are more profitable higher work GPCI 

values. Although the Institute of Medicine recommends that we continue to use proxy 
CMS-1590-P 130 

occupations in the work GPCI methodology, its regression-based approach alters each of the 

three steps described above. 

To modify the first step, the Institute of Medicine recommends that we empirically 

evaluate the validity of seven proxy occupations we currently use. The current proxy 

occupations in the work GPCI are intended to represent highly educated, professional employee 

categories. Although the Institute of Medicine recommends re-evaluating the proxy occupations 

used in the work GPCI, it does not define specific criteria to use for this purpose. 

 To modify the second step, the Institute of Medicine recommends using a regressionbased approach to weight the selected proxy occupation indices based on their correlation with 

physician earnings. This Institute of Medicine proposal would replace the current approach 

where occupations are weighted by the size of their share of total national wages. Such an 

approach presumes that wages for proxy occupations are not related to physician profits. 

Finally, the Institute of Medicine proposes an empirically-based approach to determine 

the inclusion factor for work. The inclusion factor for work refers to section 1848(e)(1)(A)(iii) 

of the Act requiring that the work GPCI reflect only 25 percent of the difference between the 

relative value of physicians’ work effort in each locality and the national average of such work 

effort. Therefore, under current law, only one quarter of the measured regional variation in 

physician wages is incorporated into the work GPCI. The Institute of Medicine recommends 

calculating an inclusion factor based on the predicted values of the regression described above. 

Under the Institute of Medicine’s approach, the inclusion factor is larger when the proxy 

occupations have a higher correlation with physicians’ earnings and smaller when the proxy 

occupations have a lower correlation with physicians’ earnings. We note that using such an 

empirical approach to weight the proxy occupation indices and to estimate the inclusion factor 

requires the identification of a viable source of physician wage information in addition to the 
CMS-1590-P 131 

wage information of proxy occupations to accurately measure regional variation in physician 

wages. 

We seek comment on the Institute of Medicine recommendations to revise the work 

GPCI methodology. In addition, we look forward to the MedPAC study on this issue required 

under section 3004 of the MCTRJCA. This study will assess whether any geographic adjustment 

to physician work is appropriate and, if so, what the level should be and where it should be 

applied. 

(D) Institute of Medicine Recommendation 5-6: A new source of information should be 

developed to determine the variation in the price of commercial office rent per square foot. 

(Geographic Adjustment in Medicare Payment, Phase I: Improving Accuracy pages 5-38 thru 5-

39) 

 The Institute of Medicine recommends the development of a new source of data to 

determine the variation in the price of commercial office rent per square foot. However, the 

Institute of Medicine does not explicitly recommend where the data should come from or how it 

should be collected. Before coming to this recommendation, the Institute of Medicine identified 

and evaluated several public and commercially available sources of data to determine whether an 

accurate alternative is available to replace the residential rent data currently used as a proxy to 

measure regional variation in physicians’ cost to rent office space in the PE GPCI; these sources 

include rental data from the U.S. Department of Housing and Urban Development, American 

Housing Survey, General Services Administration, Basic Allowance for Housing (U.S. 

Department of Defense), U.S. Postal Service, Medical Group Management Association 

(MGMA), and REIS, Inc. The Institute of Medicine concluded that these sources had substantial 

limitations, including lack of representativeness of the market in which physicians rent space, 

small sample size, low response rates, and sample biases. Although we agree that a suitable 
CMS-1590-P 132 

source for commercial office rent data would be preferable to the use of residential rent data in 

our PE office rent methodology, we have still been unable to identify an adequate commercial 

rent source that sufficiently covers rural and urban areas. We will continue to evaluate possible 

commercial rent data sources for potential use in the office rent calculation. We also encourage 

public commenters to notify us of any publicly available commercial rent data sources, with 

adequate data representation of urban and rural areas that could potentially be used in the 

calculation of the office rent component of PE. 
CMS-1590-P 133 

E. Medicare Telehealth Services for the Physician Fee Schedule

1. Billing and Payment for Telehealth Services 

a. History 

Prior to January 1, 1999, Medicare coverage for services delivered via a 

telecommunications system was limited to services that did not require a face-to-face encounter 

under the traditional model of medical care. Examples of these services included interpretation 

of an x-ray, or electrocardiogram, or electroencephalogram tracing, and cardiac pacemaker 

analysis. 

Section 4206 of the BBA provided for coverage of, and payment for, consultation 

services delivered via a telecommunications system to Medicare beneficiaries residing in rural 

health professional shortage areas (HPSAs) as defined by the Public Health Service Act. 

Additionally, the BBA required that a Medicare practitioner (telepresenter) be with the patient at 

the time of a teleconsultation. Further, the BBA specified that payment for a teleconsultation 

had to be shared between the consulting practitioner and the referring practitioner and could not 

exceed the fee schedule payment which would have been made to the consultant for the service 

furnished. The BBA prohibited payment for any telephone line charges or facility fees 

associated with the teleconsultation. We implemented this provision in the CY 1999 PFS final 

rule with comment period (63 FR 58814). 

Effective October 1, 2001, section 223 of the Medicare, Medicaid and SCHIP Benefits 

Improvement Protection Act of 2000 (Pub. L. 106-554) (BIPA) added a new section, 1834(m), to 

the Act which significantly expanded Medicare telehealth services. 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 delivered via a 

telecommunications system. We first implemented this provision in the CY 2002 PFS final rule 
CMS-1590-P 134 

with comment period (66 FR 55246). Section 1834(m)(4)(F)(ii) of the Act required the 

Secretary to establish a process that provides for annual updates to the list of Medicare telehealth 

services. We established this process in the CY 2003 PFS final rule with comment period 

(67 FR 79988). 

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 the practitioner at the distant site. 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 does allow the use of 

asynchronous “store-and-forward” technology in delivering these services when the originating 

site is 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 individual 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. Under 

the BIPA, originating sites were limited under section 1834(m)(3)(C) of the Act to specified 

medical facilities located in specific geographic areas. The initial list of telehealth originating 

sites included the office of a practitioner, a critical access hospital (CAH), a rural health clinic 
CMS-1590-P 135 

(RHC), a Federally qualified health center (FQHC) and a hospital (as defined in Section 1861(e) 

of the Act). More recently, section 149 of the Medicare Improvements for Patients and 

Providers Act of 2008 (Pub. L. 110-275) (MIPPA) expanded the list of telehealth originating 

sites to include hospital-based renal dialysis centers, skilled nursing facilities (SNFs), and 

community mental health centers (CMHCs). In order to serve as a telehealth originating site, 

these sites must be located in an area designated as a rural health professional shortage area 

(HPSA), in a county that is not in a metropolitan statistical area (MSA), or must be an entity that 

participates in a Federal telemedicine demonstration project that has been approved by (or 

receives funding from) the Secretary of Health and Human Services as of December 31, 2000. 

Finally, section 1834(m) of the Act does not require the eligible telehealth individual to be 

presented by a practitioner at the originating site. 

b. Current Telehealth Billing and Payment Policies

As noted previously, Medicare telehealth services can only be furnished to an eligible 

telehealth beneficiary in an originating site. An originating site is 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. In general, originating sites must be located in a rural HPSA or in a 

county outside of an MSA. The originating sites authorized by the statute are as follows: 

● Offices of a physician or practitioner; 

● Hospitals; 

● CAHs; 

● RHCs; 

● FQHCs; 

● Hospital-Based or Critical Access Hospital-Based Renal Dialysis Centers (including 

Satellites); 
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● SNFs; 

● CMHCs.

Currently approved Medicare telehealth services include the following: 

● Initial inpatient consultations; 

● Follow-up inpatient consultations; 

● Office or other outpatient visits; 

● Individual psychotherapy; 

● Pharmacologic management; 

● Psychiatric diagnostic interview examination; 

● End-stage renal disease (ESRD) related services; 

● Individual and group medical nutrition therapy (MNT); 

● Neurobehavioral status exam; 

● Individual and group health and behavior assessment and intervention (HBAI); 

● Subsequent hospital care; 

● Subsequent nursing facility care; 

● Individual and group kidney disease education (KDE); 

● Individual and group diabetes self-management training (DSMT); and 

• Smoking cessation services. 

In general, the practitioner at the distant site may be any of the following, provided that 

the practitioner is licensed under State law to furnish the service via a telecommunications 

system: 

● Physician; 

● Physician assistant (PA); 

● Nurse practitioner (NP); 
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● Clinical nurse specialist (CNS); 

● Nurse-midwife; 

● Clinical psychologist; 

● Clinical social worker; 

● Registered dietitian or nutrition professional. 

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. Distant site practitioners must submit the appropriate HCPCS 

procedure code for a covered professional telehealth service, appended with the –GT (Via 

interactive audio and video telecommunications system) or –GQ (Via asynchronous 

telecommunications system) modifier. By reporting the –GT or –GQ modifier with a covered 

telehealth procedure code, the distant site practitioner certifies that the beneficiary was present at 

a telehealth originating site when the telehealth service was furnished. The usual Medicare 

deductible and coinsurance policies apply to the telehealth services reported by distant site 

practitioners. 

Section 1834(m)(2)(B) of the Act provides for payment of a facility fee to the originating 

site. To be paid the originating site facility fee, the provider or supplier where the eligible 

telehealth individual is located must submit a claim with HCPCS code Q3014 (Telehealth 

originating site facility fee), and the provider or supplier is paid according to the applicable 

payment methodology for that facility or location. The usual Medicare deductible and 

coinsurance policies apply to HCPCS code Q3014. By submitting HCPCS code Q3014, the 
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originating site certifies that it is located in either a rural HPSA or non-MSA county or is an 

entity that participates in a Federal telemedicine demonstration project that has been approved by 

(or receives funding from) the Secretary of Health and Human Services as of December 31, 2000 

as specified in section 1834(m)(4)(C)(i)(III) of the Act. 

As previously described, certain professional services that are commonly furnished 

remotely using telecommunications technology, but that do not require the patient to be present 

in-person with the practitioner when they are furnished, are covered and paid in the same way as 

services delivered without the use of telecommunications technology when the practitioner is 

in-person at the medical facility furnishing care to the patient. Such services typically involve 

circumstances where a practitioner is able to visualize some aspect of the patient's condition 

without the patient being present and without the interposition of a third person's judgment. 

Visualization by the practitioner can be possible by means of x-rays, electrocardiogram or 

electroencephalogram tracings, tissue samples, etc. For example, the interpretation by a 

physician of an actual electrocardiogram or electroencephalogram tracing that has been 

transmitted via telephone (that is, electronically, rather than by means of a verbal description) is 

a covered physician's service. These remote services are not Medicare telehealth services as 

defined under section 1834(m) of the Act. Rather, these remote services that utilize 

telecommunications technology 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 (that is, without the –GT 

or –GQ modifier appended). . 

2. Requests for Adding Services to the List of Medicare Telehealth Services 
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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 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. 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 delivered 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 delivering 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 
CMS-1590-P 140 

relevant to the service when furnished via telehealth. Our evidentiary standard of clinical benefit 

does not include minor or incidental benefits. 

Some examples of clinical benefit include the following: 

● Ability to diagnose a medical condition in a patient population without access to 

clinically appropriate in person diagnostic services. 

● Treatment option for a patient population without access to clinically appropriate inperson treatment options. 

● Reduced rate of complications. 

● Decreased rate of subsequent diagnostic or therapeutic interventions (for example, due 

to reduced rate of recurrence of the disease process). 

● Decreased number of future hospitalizations or physician visits. 

● More rapid beneficial resolution of the disease process treatment. 

● Decreased pain, bleeding, or other quantifiable symptom. 

● Reduced recovery time. 

Since establishing the process to add or remove services from the list of approved 

telehealth services, we have added the following to the list of Medicare telehealth services: 

individual and group HBAI services; psychiatric diagnostic interview examination; ESRD 

services with 2 to 3 visits per month and 4 or more visits per month (although we require at least 

1 visit a month to be furnished in-person by a physician, CNS, NP, or PA in order to examine the 

vascular access site); individual and group MNT; neurobehavioral status exam; initial and 

follow-up inpatient telehealth consultations for beneficiaries in hospitals and skilled nursing 

facilities (SNFs); subsequent hospital care (with the limitation of one telehealth visit every 

3 days); subsequent nursing facility care (with the limitation of one telehealth visit every 

30 days); individual and group KDE; and individual and group DSMT (with a minimum of 
CMS-1590-P 141 

1 hour of in-person instruction to ensure effective injection training), and smoking cessation 

services. 

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, requests submitted before the end of CY 2012 will be 

considered for the CY 2014 proposed rule. Each request for adding 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, we refer readers to the CMS Website at 

www.cms.gov/telehealth/. 

3. Submitted Request and Other Additions to the List of Telehealth Services for CY 2013 

We received a request in CY 2011 to add alcohol and/or substance abuse and brief 

intervention services as Medicare telehealth services effective for CY 2013. The following 

presents a discussion of this request, and our proposals for additions to the CY 2013 telehealth 

list. 

a. Alcohol and/or Substance Abuse and Brief Intervention Services 

The American Telemedicine Association submitted a request to add alcohol and/or 

substance abuse and brief intervention services, reported by CPT codes 99408 (Alcohol and/or 

substance (other than tobacco) abuse structured screening (for example, AUDIT, DAST), and 

brief intervention (SBI) services; 15 to 30 minutes) and 99409 (Alcohol and/or substance (other 

than tobacco) abuse structured screening (for example, AUDIT, DAST), and brief intervention 
CMS-1590-P 142 

(SBI) services; greater than 30 minutes) to the list of approved telehealth services for CY 2013 

on a category 1 basis. 

We note that we assigned a status indicator of ‘‘N’’ (Noncovered) to CPT codes 99408 

and 99409 as explained in the CY 2008 PFS final rule with comment period (72 FR 66371). At 

the time, we stated that because Medicare only provides payment for certain screening services 

with an explicit benefit category, and these CPT codes incorporate screening services along with 

intervention services, we believed that these codes were ineligible for payment under the PFS. 

We continue to believe that these codes are ineligible for payment under PFS and, additionally, 

under the telehealth benefit. We do not believe it would be appropriate to make payment for 

claims using these CPT codes for the services furnished via telehealth, but not when furnished in 

person. Because CPT codes 99408 and 99409 are currently assigned a noncovered status 

indicator, and because we continue to believe this assignment is appropriate, we are not 

proposing to add these CPT codes to the list of Medicare Telehealth Services for CY 2013. 

However, we created two parallel G-codes for 2008 that allow for appropriate Medicare 

reporting and payment for alcohol and substance abuse assessment and intervention services that 

are not furnished as screening services, but that are furnished in the context of the diagnosis or 

treatment of illness or injury. The codes are HCPCS code G0396 (Alcohol and/or substance 

(other than tobacco) abuse structured assessment (for example, AUDIT, DAST) and brief 

intervention, 15 to 30 minutes) and HCPCS code G0397, (Alcohol and/or substance (other than 

tobacco) abuse structured assessment (for example, AUDIT, DAST) and intervention greater 

than 30 minutes). Since these codes are used to report comparable alcohol and substance abuse 

services under certain conditions, we believe that it would be appropriate to consider the ATA’s 

request as it applies to these services when appropriately reported by the G-codes. The ATA 

asked that CMS consider this request as a category 1 addition based on the similarities between 
CMS-1590-P 143 

these services and CPT codes 99406 (Smoking and tobacco use cessation counseling visit; 

intermediate, greater than 3 minutes up to 10 minutes) and 99407 (Smoking and tobacco use 

cessation counseling visit; intensive, greater than 10 minutes). We agree that the interaction 

between a practitioner and a beneficiary receiving alcohol and substance abuse assessment and 

intervention services is similar to their interaction in smoking cessation services. We also 

believe that the interaction between a practitioner and a beneficiary receiving alcohol and 

substance abuse assessment and intervention services is similar to the assessment and 

intervention elements of CPT code 96152 (health and behavior intervention, each 15 minutes, 

face-to-face; individual), which also is currently on the telehealth list. 

Therefore, we are proposing to add HCPCS codes G0396 and G0397 to the list of 

telehealth services for CY 2013 on a category 1 basis. Consistent with this proposal, we are also 

proposing to revise our regulations at §410.78(b) and §414.65(a)(1) to include alcohol and 

substance abuse assessment and intervention services as Medicare telehealth services. 

b. Preventive Services 

 Under our existing policy, we add services to the telehealth list on a category 1 basis 

when we determine that they are similar to services on the existing telehealth list with respect to 

the roles of, and interactions among, the beneficiary, physician (or other practitioner) at the 

distant site and, if necessary, the telepresenter. As we stated in the CY 2012 proposed rule 

(76 FR 42826) , we believe that the category 1 criteria not only streamline our review process for 

publically requested services that fall into this category, the criteria also expedite our ability to 

identify codes for the telehealth list that resemble those services already on this list. 

 During CY 2012, CMS added coverage for several preventive services through the 

national coverage determination (NCD) process as authorized by section 1861(ddd) of the Act. 

These services add to Medicare’s existing portfolio of preventive services that are now available 
CMS-1590-P 144 

without cost sharing under the Affordable Care Act. We believe that for several of these 

services, the interactions between the furnishing practitioner and the beneficiary are similar to 

services currently on the list of Medicare telehealth services. Specifically, we believe that the 

assessment, education, and counseling elements of the following services are similar to existing 

telehealth services: 

● Screening and behavioral counseling interventions in primary care to reduce alcohol 

misuse, reported by HCPCS codes G0442 (Annual alcohol misuse screening, 15 minutes) and 

G0443 (Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes). 

● Screening for depression in adults, reported by HCPCS code G0444 (Annual 

Depression Screening, 15 minutes). 

● Screening for sexually transmitted infections (STIs) and high-intensity behavioral 

counseling (HIBC) to prevent STIs, reported by HCPCS code G0445 (High-intensity behavioral 

counseling to prevent sexually transmitted infections, face-to-face, individual, includes: 

education, skills training, and guidance on how to change sexual behavior, performed semiannually, 30 minutes). 

● Intensive behavioral therapy for cardiovascular disease, reported by HCPCS code 

G0446 (Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 

15 minutes). 

● Intensive behavioral therapy for obesity, reported by HCPCS code G0447 (Face-toface behavioral counseling for obesity, 15 minutes). We believe that the interactions between 

practitioners and beneficiaries receiving these services are similar to individual KDE services 

reported by HCPCS code G0420 (Face-to-face educational services related to the care of chronic 

kidney disease; individual, per session, per one hour), individual MNT reported by HCPCS code 

G0270 (Medical nutrition therapy; reassessment and subsequent intervention(s) following second 
CMS-1590-P 145 

referral in the same year for change in diagnosis, medical condition or treatment regimen 

(including additional hours needed for renal disease), individual, face-to-face with the patient, 

each 15 minutes); CPT code 97802 (Medical nutrition therapy; initial assessment and 

intervention, individual, face-to-face with the patient, each 15 minutes); and CPT code 97803 

(Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the 

patient, each 15 minutes), and HBAI reported by CPT code 96150 (Health and behavior 

assessment (for example, health-focused clinical interview, behavioral observations, 

psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face 

with the patient; initial assessment); CPT code 96151 (Health and behavior assessment (for 

example, health-focused clinical interview, behavioral observations, psychophysiological 

monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient reassessment); CPT code 96152 (Health and behavior intervention, each 15 minutes, face-to-face; 

Individual); CPT code 96153 (Health and behavior intervention, each 15 minutes, face-to-face; 

Group (2 or more patients)); CPT code 96154 (Health and behavior intervention, each 15 

minutes, face-to-face; family (with the patient present)), all services that are currently on the 

telehealth list. 

 Therefore, we are proposing to add HCPCS codes G0442, G0443, G0444, G0445, 

G0446, and G0447 to the list of telehealth services for CY 2013 on a category 1 basis. We note 

that all coverage guidelines specific to the services would continue to apply when these services 

are furnished via telehealth. For example, when the national coverage determination requires 

that the service be furnished to beneficiaries in a primary care setting, the qualifying originating 

telehealth site must also qualify as a primary care setting. Similarly, when the national coverage 

determination requires that the service be furnished by a primary care practitioner, the qualifying 

primary distant site practitioner must also qualify as primary care practitioner. For more detailed 
CMS-1590-P 146 

information on coverage requirements for these services, we refer readers to the Medicare 

National Coverage Determinations Manual, Pub. 100-03, Chapter 1, Section 210, available at 

http://www.cms.gov/manuals/downloads/ncd103c1_Part4.pdf. Consistent with this proposal, we 

are also proposing to revise our regulations at §410.78(b) and §414.65(a)(1) to include these 

preventive services as Medicare telehealth services. 

4. Technical Correction to Include Emergency Department Telehealth Consultations in 

Regulation 

In the CY 2012 PFS final rule with comment period (76 FR 73103), we finalized our 

proposal to change the code descriptors for initial inpatient telehealth consultation G-codes to 

reflect telehealth consultations furnished to emergency department patients in addition to 

inpatient telehealth consultations effective January 1, 2012. However, we did not amend the 

description of the services within the regulation at §414.65(a)(1)(i). Therefore, we are proposing 

to make a technical revision to our regulation at §414.65(a)(1)(i) to reflect telehealth 

consultations furnished to emergency department patients in addition to hospital and SNF 

inpatients. 
CMS-1590-P 147 

F. Extension of Payment for Technical Component of Certain Physician Pathology Services

1. Background and Statutory Authority 

Section 542(c) of the Medicare, Medicaid, and SCHIP Benefits Improvement and 

Protection Act of 2000 (BIPA) (Pub. L. 106–554) provided payment to independent laboratories 

furnishing the technical component (TC) of physician pathology services to fee-for-service 

Medicare beneficiaries who are inpatients or outpatients of a covered hospital for a 2-year period 

beginning on January 1, 2000. This section has been amended by section 732 of the Medicare 

Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) (Pub. L. 108–173), 

section 104 of division B of the Tax Relief and Health Care Act of 2006 (MIEA–TRHCA) 

(Pub. L. 109–432), section 104 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 

(MMSEA) (Pub. L. 110–173), section 136 of the Medicare Improvements for Patients and 

Providers Act of 2008 (MIPPA) (Pub. L. 110–275), section 3104 of the Affordable Care Act 

(Pub. L. 111–148), section 105 of the Medicare and Medicaid Extenders Act of 2010 (MMEA) 

(Pub. L. 111–309), section 305 of the Temporary Payroll Tax Cut Continuation Act of 2011 

(Pub. L. 112-78) and section 3006 of the Middle Class Tax Relief and Job Creation Act of 2012 

(Pub. L. 112-96) to continue payment to independent laboratories furnishing the technical 

component (TC) of physician pathology services to fee-for-service Medicare beneficiaries who 

are inpatients or outpatients of a covered hospital for various time periods. As discussed in detail 

below, Congress most recently acted to continue this payment through June 30, 2012. The TC of 

physician pathology services refers to the preparation of the slide involving tissue or cells that a 

pathologist interprets. The professional component (PC) of physician pathology services refers 

to the pathologist’s interpretation of the slide. 

When the hospital pathologist furnishes the PC service for a hospital patient, the PC 

service is separately billable by the pathologist. When an independent laboratory’s pathologist 
CMS-1590-P 148 

furnishes the PC service, the PC service is usually billed with the TC service as a combined or 

global service. 

Historically, any independent laboratory could bill the Medicare contractor under the PFS 

for the TC of physician pathology services for hospital patients even though the payment for the 

costs of furnishing the pathology service (but not its interpretation) was already included in the 

bundled inpatient stay payment to the hospital. In the CY 2000 PFS final rule with comment 

period (64 FR 59408 and 59409), we stated that this policy has contributed to the Medicare 

program paying twice for the TC service: (1) To the hospital, through the inpatient prospective 

payment rate, when the patient is an inpatient; and (2) To the independent laboratory that bills 

the Medicare contractor, instead of the hospital, for the TC service. While the policy also 

permits the independent laboratory to bill for the TC of physician pathology services for hospital 

outpatients, in this case, there generally would not be duplicate payment because we would 

expect the hospital to not also bill for the pathology service, which would be paid separately to 

the hospital only if the hospital were to specifically bill for it. We further indicated that we 

would implement a policy to pay only the hospital for the TC of physician pathology services 

furnished to its inpatients. 

Therefore, in the CY 2000 PFS final rule with comment period, we revised §415.130(c) 

to state that for physician pathology services furnished on or after January 1, 2001 by an 

independent laboratory, payment is made only to the hospital for the TC of physician 

pathology services furnished to a hospital inpatient. Ordinarily, the provisions in the PFS final 

rule with comment period are implemented in the following year. However, the change to 

§415.130 was delayed 1-year (until January 1, 2001), at the request of the industry, to allow 

independent laboratories and hospitals sufficient time to negotiate arrangements. 

Full implementation of §415.130 was further delayed by section 542 of the BIPA and 
CMS-1590-P 149 

section 732 of the MMA, which directed us to continue payment to independent laboratories for 

the TC of physician pathology services for hospital patients for a 2-year period beginning on 

January 1, 2001 and for CYs 2005 and 2006, respectively. In the CY 2007 PFS final rule with 

comment period (71 FR 69788), we amended §415.130 to provide that, for services furnished 

after December 31, 2006, an independent laboratory may not bill the carrier for the TC of 

physician pathology services furnished to a hospital inpatient or outpatient. However, section 

104 of the MIEA–TRHCA continued payment to independent laboratories for the TC of 

physician pathology services for hospital patients through CY 2007, and section 104 of the 

MMSEA further extended such payment through the first 6 months of CY 2008. 

Section 136 of the MIPPA extended the payment through CY 2009. Section 3104 of the 

Affordable Care Act amended the prior legislation to extend the payment through CY 2010. 

Section 105 of the MMEA extended the payment through CY 2011. Subsequent to publication 

of the CY 2012 PFS final rule with comment period, section 305 of the Temporary Payroll Tax 

Cut Continuation Act of 2011 extended the payment through February 29, 2012 and section 3006 

of the Middle Class Tax Relief and Job Creation Act of 2012 extended the payment through 

June 30, 2012. t15>2010 16:57 Nov 25, 2011 700 E:\FR\FM\28NOR2.SGM 28NOR2 

2. Revisions to Payment for TC of Certain Physician Pathology Services

In the CY 2012 PFS final rule with comment period, we finalized our policy that an 

independent laboratory may not bill the Medicare contractor for the TC of physician pathology 

services furnished after December 31, 2011, to a hospital inpatient or outpatient (76 FR 73278 

through 73279, 73473). As discussed above, subsequent to publication of this final rule with 

comment period, Congress acted to continue payment to independent laboratories through June 

30, 2012. Therefore, the policy that we finalized in the CY 2012 PFS final rule with comment 

period is superseded by statute for six months. To be consistent with the statutory changes and 
CMS-1590-P 150 

our current policy, we are proposing conforming changes to §415.130(d) such that we will 

continue payment under the PFS to independent laboratories furnishing the TC of physician 

pathology services to fee-for-service Medicare beneficiaries who are inpatients or outpatients of 

a covered hospital on or before June 30, 2012. Independent laboratories may not bill the 

Medicare contractor for the TC of physician pathology services furnished after June 30, 2012, to 

a hospital inpatient or outpatient. 

G. Therapy Services

1. Outpatient Therapy Caps for CY 2013 

 Section 1833(g) of the Act applies annual, per beneficiary, limitations (therapy caps) on 

expenses incurred for outpatient therapy services under Medicare Part B. There is one therapy 

cap for physical therapy (PT) and speech-language pathology (SLP) services combined and a 

second separate therapy cap for outpatient occupational therapy (OT) services. Although therapy 

services furnished in an outpatient hospital setting have been exempt from the application of the 

therapy caps, section 3005(b) of the MCTRJCA amended section 1833(g) of the Act to require 

therapy services furnished in an outpatient hospital setting during 2012 be subject to the therapy 

caps beginning not later than October 1, 2012. 

 The therapy caps amount for CY 2013 will be announced in the CY 2013 PFS final rule 

with comment period. The annual change in each therapy cap is computed by multiplying the 

cap amount for CY 2012, which is $1,880, by the MEI for CY 2013, then rounding to the nearest 

$10. This amount is added to the CY 2012 therapy cap amount to obtain the CY 2013 therapy 

cap amount. 

 An exceptions process to the therapy caps has been in effect since January 1, 2006 -- 

originally authorized by section 5107 of the DRA, which amended section 1833(g)(5) of the Act. 

Since that time, the exceptions process for the therapy caps has been extended through 
CMS-1590-P 151 

subsequent legislation (MIEA-TRHCA, MMSEA, MIPPA, the Affordable Care Act, MMEA, 

and TPTCCA). Last amended by section 3005 of the MCTRJCA, the Agency's authority to 

provide for an exception process to therapy caps expires on December 31, 2012. To request an 

exception to the therapy caps, therapy suppliers and providers use the KX modifier on claims for 

services that are over the cap amount. Use of the KX modifier indicates that the services are 

reasonable and necessary and that there is documentation of medical necessity in the 

beneficiary’s medical record. 

 Section 3005 of the MCTRJCA also requires two additional changes to Medicare 

policies for outpatient therapy services. Section 3005(a)(5) adds a new subparagraph (C) to 

section 1833(g)(5) of the Act, effective October 1 through December 31, 2012, that requires 

application of a manual medical review process (similar to the process used in 2006 for certain 

therapy cap exceptions) for exceptions to the therapy caps after expenses incurred for the 

beneficiary’s therapy services (including services furnished in a hospital outpatient department) 

exceed the threshold of $3,700 for the year. As with the therapy caps, there are two separate 

thresholds for the manual medical review process – one threshold of $3,700 for PT and SLP 

services combined and one threshold of $3,700 for OT services. Requests for exceptions to the 

therapy caps for services above the thresholds are subject to a manual medical review process. 

The applicable amount of expenses incurred for therapy services counted towards these 

thresholds for the year begins on January 1, 2012. Since the exceptions process is set to expire 

on December 31, 2012, the requirement for a manual medical review process will also expire 

then. 

 Section 3005(c) adds a new section 1842(t)(2) to the Act, effective beginning on 

October 1, 2012, that requires the National Provider Identifier (NPI) of the physician (or NPP, 

where applicable), who periodically reviews the therapy plan of care, to be reported on the claim 
CMS-1590-P 152 

for therapy services. This reporting requirement applies to all claims for outpatient therapy 

services. 

2. Claims-Based Data Collection Strategy for Therapy Services 

a. Introduction 

Section 3005(g) of the MCTRJCA requires CMS to implement, beginning on January 1, 

2013, “. . . a claims-based data collection strategy that is designed to assist in reforming the 

Medicare payment system for outpatient therapy services subject to the limitations of section 

1833(g) of the Act. Such strategy shall be designed to provide for the collection of data on 

patient function during the course of therapy services in order to better understand patient 

condition and outcomes.” 

b. History/Background 

In 2010, more than 7.6 million Medicare beneficiaries received outpatient therapy 

services, including physical therapy (PT), occupational therapy (OT), and speech-languagepathology (SLP). Medicare payments for these services exceeded $5.6 billion. Between 1998–

2008, Medicare expenditures for outpatient therapy services increased at a rate of 10.1 percent 

per year while the number of Medicare beneficiaries receiving therapy services only increased by 

2.9 percent per year. Although a significant number of Medicare beneficiaries benefit from 

therapy services, the rapid growth in Medicare expenditures for these services has long been of 

concern to the Congress and the Agency. To address this concern, efforts have been focused on 

developing Medicare payment incentives that encourage delivery of reasonable and necessary 

care while discouraging overutilization of therapy services and the provision of medically 

unnecessary care. A brief review of these efforts is useful in understanding our proposal for CY 

2013. 

(1) Therapy Caps 
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 Section 4541 of the Balanced Budget Act of 1997 (Pub. L. 105-33) (BBA) amended 

section 1833(g) of the Act to impose financial limitations on outpatient therapy services (the 

"therapy caps” discussed above) in an attempt to limit Medicare expenditures for therapy 

services. Prior to the BBA amendment, these caps had applied to services furnished by 

therapists in private practice, but the BBA expanded the caps effective January 1, 1999, to 

include all outpatient therapy services except those furnished in outpatient hospitals. Since that 

time, the Congress has amended the statute several times to impose a moratorium on the 

application of the caps or has required us to implement an exceptions process for the caps. The 

therapy caps have only been in effect without an exceptions process for less than two years. (See 

the discussion about the therapy cap exceptions process above.) Almost from the inception of 

the therapy caps, the Congress and the Agency have been exploring potential alternatives to the 

therapy caps. 

(2) Multiple Procedure Payment Reduction (MPPR) 

 In the CY 2011 PFS final rule with comment period (75 FR 73232-73242), we adopted a 

MPPR of 25 percent applicable to the practice expense (PE) component of the second and 

subsequent therapy services when more than one of these services is furnished in a single 

session. This reduction applies to nearly 40 therapy services. (For a list of therapy services to 

which this policy applies, see Addenda H.) The Physician Payment and Therapy Relief Act of 

2010 (PPTRA) subsequently revised the reduction to 20 percent for services furnished in an 

office setting, leaving the 25 percent reduction in place for services furnished in institutional 

settings. We adopted this MPPR as part of our directive under section 1848(c)(2)(k) of the 

statute (as added by section 3134(a) of the Affordable Care Act) to identify and evaluate 

potentially misvalued codes. By taking into consideration the expected efficiencies in direct PE 

resources that occur when services are furnished together, this policy results in more appropriate 
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payment for therapy services. Although we did not adopt this MPPR policy specifically as an 

alternative to the therapy caps, paying more appropriately for combinations of therapy services 

that are commonly furnished in a single session reduces the number of beneficiaries impacted by 

the therapy caps in a given year. For more details on the MPPR policy, see section II.C.4. of this 

proposed rule. 

(3) Studies Performed 

A uniform dollar value therapy cap sets a limit on the volume of services furnished 

unrelated to the specific services furnished or the beneficiary’s condition or needs. One uniform 

cap does not deter unnecessary care or encourage efficient practice for low complexity 

beneficiaries. In fact, it may even encourage the provision of services up to the level of the cap. 

Conversely, a uniform cap without an exceptions process restricts necessary and appropriate care 

for certain high complexity beneficiaries. Recognizing these limitations in a uniform dollar 

value cap, we have been studying therapy practice patterns and exploring ways to refine payment 

for these services as an alternative to therapy caps. 

On November 9, 2004, the Secretary delivered the Report to Congress, as required by the 

BBA as amended by the BBRA, "Medicare Financial Limitations on Outpatient Therapy 

Services." That report included two utilization analyses. Although these analyses provided 

details on utilization, neither specifically identified ways to improve therapy payment. In the 

report, we indicated that further study was underway to assess alternatives to the therapy caps. 

The report and the analyses are available on the CMS Website at 

http://www.cms.gov/TherapyServices/. 

Since 2004, we have periodically updated the utilization analyses and posted other 

reports on the CMS Website to respond to the additional BBRA requirements. Subsequent 

reports highlighted the expected effects of limiting services in various ways and presented plans 
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to collect data about beneficiary condition, including functional limitations, using available tools. 

Through these efforts, we have made progress in identifying the outpatient therapy services that 

are billed to Medicare, the demographics of the beneficiaries who utilize these services, the types 

of therapy services furnished, the HCPCS codes used to bill the services, the allowed and paid 

amounts of the services, the providers of these services, the states in which the services are 

furnished and the type of practitioner furnishing services. 

From these and other analyses in our ongoing research effort, we have concluded that 

without the ability to define the services that are typically needed to address specific clinical 

cohorts of beneficiaries (those with similar risk-adjusted conditions), it is not possible to develop 

payment policies that encourage the delivery of reasonable and necessary services while 

discouraging the provision of services that do not produce a clinical benefit. Although there is 

widespread agreement that beneficiary condition and functional limitations are critical to 

developing and evaluating an alternative payment system for therapy services, a system for 

collecting such data does not exist. Diagnosis information is available from Medicare claims. 

However, we believe that the primary diagnosis on the claim is a poor predictor for the type and 

duration of therapy services required. Much additional work is needed to develop an appropriate 

system for classifying clinical cohorts. 

A 5-year CMS project titled "Development of Outpatient Therapy Payment Alternatives" 

(DOTPA) is expected to provide some of this information. The project is now in its final stages 

of data collection. The purpose of the DOTPA project is to identify a set of measures that we 

could routinely and reliably collect in support of payment alternatives to the therapy caps. 

Specifically, the measures being collected are to be assessed in terms of their administrative 

feasibility and their usefulness in identifying beneficiary need for outpatient therapy services and 

the outcomes of those services. A final report is expected during the second half of CY 2013. In 
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addition to developing alternatives to the therapy caps, the DOTPA project reflects our interest in 

value-based purchasing by identifying components of value, namely, beneficiary need and the 

effectiveness of therapy services. Although we expect DOTPA to provide meaningful data and 

practical information to assist in developing improved methods of paying for appropriate therapy 

services, DOTPA will not deliver a standardized measurement instrument for use in outpatient 

therapy services. Further, it is unlikely that this one project alone will provide adequate 

information to implement a new payment system for therapy. This study combined with data 

from a wider group of Medicare beneficiaries would enhance our ability to develop alternative 

payment policy for outpatient therapy services. 

c. Proposal 

(1) Overview 

As required by section 3005(g) of MCTRJCA, we are proposing to implement a claimsbased data collection strategy on January 1, 2013. This claims-based data collection system is 

designed to gather information on beneficiary function and condition, therapy services furnished, 

and outcomes achieved. This information will assist in reforming the Medicare payment system 

for outpatient therapy services. By collecting data on beneficiary function over an episode of 

therapy services, we hope to better understand the Medicare beneficiary population that uses 

therapy services, how their functional limitations change as a result of therapy services, and the 

relationship between beneficiary functional limitations and furnished therapy services over an 

episode of care. The term “functional limitation” generally encompasses both the terms “activity 

limitations” and “participation restrictions” as described by the International Classification of 

Functioning, Disability and Health (ICF). (For information on ICF, see 

http://www.who.int/classifications/icf/en/ and for specific ICF nomenclature (including activity 

limitations and participation restrictions), see http://apps.who.int/classifications/icfbrowser/.) 
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We are proposing to encompass, under this proposal, the Medicare Part B outpatient 

therapy benefit and PT, OT, and SLP under the Comprehensive Outpatient Rehabilitation 

Facilities (CORF) benefit. “Incident to” therapy services furnished by physicians or 

nonphysician practitioners (NPPs) would also be included. This broad applicability would 

include services furnished in hospitals, critical access hospitals (CAHs), skilled nursing facilities 

(SNFs), CORFs, rehabilitation agencies, and home health agencies (when the beneficiary is not 

under a home health plan of care) and private offices. 

When used in this section “therapists” means all practitioners who furnish outpatient 

therapy services, including physical therapists, occupational therapists, and speech-language 

pathologists in private practice and those therapists who furnish services in the institutional 

settings, physicians and NPPs (including, physician assistants (PAs), nurse practitioners (NPs), 

clinical nurse specialists (CNSs), as applicable.) 

This proposal is based upon an option for claims-based data collection that was discussed 

during the CY 2011 rulemaking (75 FR 40096 through 40100 and 73284 through 73293). This 

option was developed under a contract with CMS as part of the Short Term Alternatives for 

Therapy Services (STATS) project. The STATS project provided three options for alternative 

payment to the therapy caps that could be considered in the short-term before completion of the 

DOTPA project. In developing options, the STATS project drew upon the analytical expertise of 

CMS contractors and the clinical expertise of various outpatient therapy stakeholders to consider 

policies and available claims data. The options developed were: 

● Capturing additional clinical information regarding the severity and complexity of 

beneficiary functional impairments on therapy claims in order to facilitate medical review and at 

the same time gather data that would be useful in the long term to develop a better payment 

mechanism; 
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● Introducing additional claims edits regarding medical necessity, in order to reduce 

overutilization; and 

● Adopting a per-session bundled payment that would vary based on beneficiary 

characteristics and the complexity of evaluation and treatment services furnished in a session. 

While we did not propose to adopt any of these alternatives at that time, we discussed 

these three options during the CY 2011 rulemaking and solicited public comments on all aspects 

of these alternatives, including the potential associated benefits or problems, clinical concerns, 

practitioner administrative burden, consistency with other Medicare and private payer payment 

policies, and claims processing considerations. In general, public commenters on the data 

collection effort questioned the ability to collect the needed information using this type of 

system. Commenters raised specific concerns about the training and education of therapists that 

would be needed prior to implementation. Although concerns were expressed about claimsbased data reporting, no one questioned the need for data on beneficiary condition and functional 

limitations. The Congress has now included in section 3005(g) of the MCTRJCA a requirement 

to implement a claims-based data collection effort. While the proposed system is based upon the 

data collection alternative discussed in the CY 2011 PFS rulemaking, it has been modified in 

response to the comments received on the CY 2011 proposed rule. 

The long-term goal is to develop an improved payment system for Medicare therapy 

services. The desired payment system would pay appropriately and similarly for efficient and 

effective services furnished to beneficiaries with similar conditions and functional limitations 

who have good potential to benefit from the services furnished. Importantly, such a system 

would not encourage the furnishing of medically unnecessary or excessive services. At this time, 

the data on Medicare beneficiaries’ use and benefit from therapy services from which to develop 

an improved system does not exist. This proposed data collection effort would be the first step 
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towards collecting the data needed for this type of payment reform. Once the initial data have 

been collected and analyzed, we expect to be able to identify gaps in information and determine 

what additional data are needed to develop a new payment policy. Without a better 

understanding of the diversity of beneficiaries receiving therapy services and the variations in 

type and volume of treatments provided, we lack the information to develop a comprehensive 

strategy to map the way to an improved payment policy. While this claims-based data collection 

proposal is only the first step in a long-term effort, it is an essential step. 

We are proposing to require that claims for therapy services include nonpayable G-codes 

and modifiers. Through the use of these codes and modifiers, we would capture data on the 

beneficiary’s functional limitations (a) at the outset of the therapy episode, (b) at specified points 

during treatment and (c) at discharge from the outpatient therapy episode of care. In addition, 

the therapist’s projected goal for functional status at the end of treatment would be reported on 

the first claim for services and periodically throughout an episode of care. 

Specifically, G-codes would be used to identify what is being reported – current status, 

goal status or discharge status. Modifiers would indicate the extent of the severity/complexity of 

the functional limitation being tracked. The difference between the reported functional status at 

the start of therapy and projected functional status at the end of the course of therapy represents 

the progress the therapist anticipates the beneficiary would make during the course of 

treatment/episode of care. As the beneficiary progresses through the course of treatment, one 

would expect progress toward the goal established by the therapist. 

By tracking changes in functional limitations throughout the therapy episode and at 

discharge, we would have information about the furnished therapy services and the outcomes of 

such services. The ICD-9 diagnosis codes reported on the claim form would provide information 

on beneficiary condition. 
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Since 2006, we have paid claims for therapy services that exceed the annual per 

beneficiary caps when the claims include the KX modifier. The presence of the KX modifier on 

a therapy claim indicates that the therapist attests that the services on the claim are medically 

necessary and that the justification for medical necessity is documented in the beneficiary’s 

medical record. We propose to apply the additional G-code and modifier reporting requirements 

to all claims, including claims with the KX modifier and those subject to any manual medical 

review process, if such manual medical review or the KX modifier were applicable, after 

December 31, 2012. (See the discussion about therapy caps above.) 

(2) Proposed Nonpayable G-Codes on Beneficiary Functional Status 

For the proposed reporting, therapists would report G-codes and modifiers on Medicare 

claims for outpatient therapy services. Table 17 shows the proposed G-codes and their 

definitions. (An appropriate status indicator will be assigned to these codes if finalized.) 

TABLE 17: Proposed Nonpayable G-Codes for Reporting Functional Limitations. 

Functional limitation for primary functional limitation 

GXXX1 Primary Functional limitation Current status at initial 

treatment/episode outset and at 

reporting intervals 

GXXX2 Primary Functional limitation Projected goal status 

GXXX3 Primary Functional limitation Status at therapy discharge or end 

of reporting 

Functional limitation for a secondary functional limitation if one exists 

GXXX4 Secondary Functional limitation Current status at initial 

treatment/outset of therapy 

and at reporting intervals 

GXXX5 Secondary Functional limitation Projected goal status 

GXXX6 Secondary Functional limitation Status at therapy discharge or end 

of reporting 

Provider attestation that functional reporting not required 

GXXX7 Provider confirms functional 

reporting not required 

The proposed claims-based data collection system using G-codes and severity modifiers 

builds upon current Medicare requirements for therapy services. Section 410.61 requires that a 
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therapy plan of care (POC) be established before treatment begins. This POC must include: the 

type, amount, frequency, and duration of the PT, OT, SLP services to be furnished to each 

beneficiary, the diagnosis and the anticipated goals. Section 410.105(c) contains similar 

requirements for services furnished in the CORF setting. We have long encouraged therapists, 

through our manual provisions, to express the POC-required goals for each beneficiary in terms 

that are measureable and relate to identified functional impairments. See Pub 100-02, Chapter 

15, Section 220.1.2. The evaluation and the goals developed as part of the POC would be the 

foundation for the initial reporting under the proposed system. 

Using the first set of G-codes (GXXX1, GXXX2, and GXXX3) with appropriate 

modifiers, the therapist would report the beneficiary’s primary functional limitation or the most 

clinically relevant functional limitation at the time of the initial therapy evaluation and the 

establishment of the POC. In combination with appropriate modifiers, these G-codes would 

describe the current functional limitation (GXXX1) and the projected goal (GXXX2) for the 

functional limitation and the status at the end of a course of therapy (GXXX3). At specified 

intervals during treatment, claims would also include GXXX1 to show the status at that time and 

GXXX2 to show the goal, which would not change during therapy, except as described below. 

At the time the beneficiary is discharged from therapy, the final claim for this episode of care 

would use GXXX2 to show the goal and GXXX3 to denote status at the end of reporting for this 

functional limitation. 

Therapists frequently use measurement tools to quantify beneficiary function. The 

Patient Inquiry by Focus on Therapeutic Outcomes, Inc (FOTO) and the National Outcomes 

Measurement System (NOMS) by the American Speech-Language-Hearing Association (ASHA) 

are two such assessment tools in the public domain that can be used to determine a composite or 

overall score for an assessment of beneficiary function. Therapists could use the score produced 
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by such measurement tools, provided they are valid and reliable, to select the appropriate 

modifier for reporting the beneficiary’s functional status. While we support the use of 

consistent, objective tools to determine beneficiary functional limitation, for several reasons, at 

this time we are not endorsing, nor are we proposing to require, use of a particular tool to 

determine the severity modifier discussed in the next section. Some tools are proprietary, and 

others in the public domain cannot be modified to explicitly address this data collection project. 

Further, this data collection effort spans several therapy disciplines. Requiring a specific 

instrument could create burdens for therapists that would have to be considered in light of any 

potential improvement in data accuracy, consistency and appropriateness that such an instrument 

would generate. We may reconsider this decision once we have more experience with claimsbased data collection on beneficiary function associated with furnished therapy services. We are 

seeking public comment on the use of assessment tools. In particular, we are interested in 

feedback regarding the benefits and burdens associated with use of a specific tool to assess 

beneficiary functional limitations. We request that those favoring a requirement to use a specific 

tool provide information on the preferred tool and describe why the tool is preferred. 

Early results from the DOTPA project suggest that most beneficiaries have more than one 

functional limitation at treatment outset. In fact, only 21 percent of the DOTPA assessments 

reported just one functional limitation. Slightly more than half (54 percent) reported two, three 

or four functional limitations. 

To the extent that the DOTPA experience is typical, the therapist may need to make a 

determination as to which functional limitation is primary for reporting purposes. In cases where 

this is unclear, the therapist may choose the functional limitation that is most clinically relevant 

to a successful outcome for the beneficiary, the one that would yield the quickest and greatest 

mobility, or the one that is the greatest priority for the beneficiary. In all cases, this primary 
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functional limitation should reflect the predominant limitation that the furnished therapy services 

are intended to address. 

To allow for more complete reporting, the second set of G-codes in Table 17 could be 

used to describe a secondary functional limitation, when one exists. Two examples demonstrate 

the applicability of the second set of G-codes. 

(1) A beneficiary under a PT plan of care is being treated simultaneously for mobility 

restriction, for example, “walking and moving” (including, for example, climbing stairs) due to 

complications following a total knee replacement and for a “self-care” restriction due to a 

stabilized and immobilized upper extremity after a shoulder dislocation. 

(2) A beneficiary under a SLP plan of care may be treated simultaneously for both a 

swallowing dysfunction and a communication impairment resulting from a stroke. 

This secondary G-code set is used to report the functional limitation that the therapist 

considers secondary to the primary one at the outset of a course of therapy. For example, in the 

first scenario above, the therapist determines the “self-care” to be secondary to the beneficiary’s 

primary one (“walking and moving”). The therapist would report the secondary functional 

limitation using a current status (GXXX4) along with the associated goal ( GXXX5). 

In some cases, a secondary functional limitation may not develop or be identified until 

after the course of treatment has begun. In such situations, the therapist would begin reporting 

this secondary set at the time the functional limitation is identified. Just as in the example above, 

the therapist would report GXXX4 and GXXX5. 

For beneficiaries having more than two functional limitations, once the goal for the 

primary functional limitation has been reached or the beneficiary’s potential to reach the goal has 

been maximized, the reporting on that functional limitation ends and reporting can begin on a 

new functional limitation. The therapist would use the set of G-codes (and associated modifiers) 
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for the primary functional limitation, that is, GXXX1 - GXXX3, to report functional status of the 

beneficiary’s third functional restriction. This process of adding a new functional limitation, for 

example, for the fourth and the fifth, can continue until therapy ends. Following this process, the 

set of G-codes that the therapist uses originally to report each functional limitation does not 

change throughout the episode of care, even though the originally reported secondary functional 

limitation (reported with GXXX4 through GXXX6) may have become the primary one, for 

clinical purposes, once the goal for the originally reported primary functional limitation was 

reached. The therapist is not expected to change the G-code set used originally to report a 

particular functional limitation; we believe requiring therapists to do so would be too 

burdensome and would confuse the data we are collecting for programmatic purposes. 

We are seeking comment on specific issues regarding reporting data on a secondary 

limitation. Specifically, we request comments regarding whether reporting on secondary 

functional limitations should be required or optional. We would also be interested in information 

regarding what percentage of Medicare therapy beneficiaries has more than one functional 

limitation at the outset of therapy, and for those with multiple functional limitations, what is the 

average number. We would also be interested in information on the percentage of these 

functional limitations for which therapists go on to measure, document, and develop related 

therapy goals. 

The proposed G-codes differ from the three separate pairs of G-codes discussed in the 

CY 2011 PFS rulemaking. The CY 2011 discussion included these three pairs of G-codes, all of 

which are reflect specific ICF terminology: 

● Impairments of Body Functions and/or Impairments of Body Structures; 

● Activity Limitations and Participation Restrictions; and 

● Environmental Factors Barriers. 
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Each pair contained a G-code to represent the beneficiary’s current functional status and another 

G-code to represent the beneficiary’s projected goal status. Like the G-codes in this proposal, 

these G-codes would have been used with modifiers to reflect the severity/complexity of each 

element. 

This set of G-codes appeared to us to be potentially redundant and confusing since we are 

using the term functional limitations to be synonymous with the ICF terminology “activity 

limitations and participation restrictions.” Requiring separate reporting on three elements would 

have imposed a burden on therapists without providing a meaningful benefit in the value of the 

data provided. Further, because environmental barriers as discussed in CY 2011 are contextual, 

we do not believe collecting information on them would contribute to developing an improved 

payment system or assist with medical review. Since our goal is to develop a system that 

imposes the minimal additional burden while providing adequate data to accomplish the statutory 

directive (to assist in reforming the Medicare payment system for outpatient therapy services), 

we are proposing to require that just one set of G-codes be used for reporting the primary 

functional limitation. We added a second set of G-codes for a secondary functional limitation, 

which are identical to those used for the primary functional limitation. We are interested in 

public comment on the whether these proposed G-codes allow adequate reporting on 

beneficiary’s functional limitations. We would particularly appreciate receiving specific 

suggestions for any missing elements. 

(3) Severity/Complexity Modifiers 

For each functional G-code used on a claim, a modifier would be required to report the 

severity/complexity for that functional limitation. We propose to adopt a 12-point scale to report 

the severity or complexity of the functional limitation involved. The proposed modifiers are 

listed in Table 18. 
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TABLE 18: Proposed Modifiers 

Modifier Impairment Limitation 

Restriction Difficulty 

XA 0% 

XB Between 1-9% 

XC Between 10 - 19% 

XD Between 20 - 29% 

XE Between 30 - 39% 

XF Between 40 - 49% 

XG Between 50 - 59% 

XH Between 60 - 69% 

XI Between 70 - 79% 

XJ Between 80 - 89% 

XK Between 90 - 99% 

XL 100% 

An example of how a therapist would translate data from another assessment tool to this 

scale may be helpful. In our example, the physical therapist used the Berg Balance Scale (the 

long original version) to document the beneficiary’s functional balance restriction and the 

beneficiary’s test score is 33. (The scores on this test range from 0 – 56. A score below 41 is 

considered to be at moderate risk of falling.) Once the test is completed, the therapist maps the 

beneficiary’s score to our severity modifier scale. To do so, the beneficiary’s score must first be 

converted to a percentage. A score of 33 on a scale of 56 would equal 59 percent. To map the 

percentage from the Berg Balance Scale to the modifier scale, it must be subtracted from 100, 

since zero on the Berg Balance Scale reflects 100 percent limitation/disability. When 59 percent 

is subtracted from 100 percent, the result is 41 percent. This number falling between 40 percent 

and 49 percent is mapped to the severity modifier of “XF.” 

As already noted, there are many other valid and reliable measurement tools that 

therapists use to quantify functional limitations. Among these are four assessment tools we 

discussed in CY 2011 PFS rulemaking – namely, the Activity Measure – Post Acute Care (AMPAC) tool, the FOTO Patient Inquiry, OPTIMAL, and NOMS. We list these tools as 
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recommended for use by therapists, though not required, in the outpatient therapy IOM provision 

of the Benefits Policy Manual, Chapter 15, Section 220.3C “Documentation Requirements for 

Therapy Services.” The scores from these and other measurement tools already in use by 

therapy disciplines produce numerical or percentage scores that can be mapped or crosswalked to 

the proposed severity modifier scale. The advantage of using an assessment tool that yields a 

composite score, such as NOMS, would be that only the G-codes for the primary functional 

limitation would need to be reported even if we required reporting of secondary limitations. 

 In assessing the ability of therapists to provide the required severity information 

regardless of what assessment tool they use, if any, we considered the comments received on the 

CY 2011 PFS proposed rule discussion and our preliminary experience from the DOTPA project. 

Both indicated that we needed greater granularity in our severity scale to more accurately assess 

changes in functional limitation over the course of therapy. Specifically, most commenters 

favored the 7-point scale over the 5-point ICF-based scale. They preferred a scale with more 

severity levels since it would allow the therapist to document smaller changes that many therapy 

beneficiaries make towards their goals. For example, the “severe” level of the 5-point scale 

includes a 45-point spread (from 50 - 95 percent) making it difficult to document a change or 

improvement in a beneficiary’s condition whose limitation being rated falls into this category. 

Commenters also liked the equal increments of the 7-point scale. 

We believe that neither the five- or seven-point scales are adequate for this reporting 

system, and developed a new scale. The 12-point scale we are proposing is an enhancement of 

the 7-point scale. It achieves the ability to more accurately capture changes in functional 

limitations over the course of treatment and is easier to use and understand. It addresses the 

concern of a major association, which supported the 7-point scale, but suggested that an even 

more sensitive rating scale (one with more increments) might be necessary to show progress of 
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certain beneficiaries toward their projected goals, particularly those beneficiaries with 

neurological conditions, such as strokes. In addition, the proposed scale’s 10-percentage point 

increments make it easier for therapists to convert composite and overall scores from assessment 

instruments or other measurement tools to this scale. 

(4) Adaptation for G-Codes by Select Categories of Functional Limitations 

 The ultimate goal of gathering information on beneficiary function is to have adequate 

information to develop an alternative payment system for therapy services. Although the 

information that would be collected pursuant to the proposal discussed above would greatly 

increase our understanding of the therapy services furnished and any progress made as a result of 

these services, it would leave us far short of the data needed for developing a new payment 

system. A significant limitation of this proposal is that it would not provide data by type of 

functional limitation involved. We have been unable to identify an existing system that 

categorizes the variety of functional limitations addressed by therapists. Without an existing 

system that could be used to collect data on specific functional limitations, we could not develop 

and implement a complete system categorizing all functional limitations within the time period 

allowed by the statute. 

However, we could begin to collect data on select categories of functional limitations by 

adapting the reporting system described above to include some category specific-reporting in 

addition to the generic reporting. Should we decide to use a system with category-specific 

reporting, we would expect to develop specific nonpayable G-codes for select categories of 

functional limitations in the final rule. Under this adaptation, if one of the select categories of 

functional limitations created describes the functional limitation being reported, that G-code set 

would be used to report the current, projected goal, and discharge status of the beneficiary. 

Any functional limitation not identified in this limited G-code set would be reported using the 
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generic G-codes previously described. 

To demonstrate this approach, we have created G-codes that describe the two most 

frequently reported functional limitations by each of the three therapy disciplines in the DOTPA 

project. (See Table 19.) When appropriate, these G-codes would be used exactly as the generic 

ones. 

TABLE 19: Select Categories of G-Codes 

Walking & Moving Around 

Walking & moving around functional limitation, current status at time of initial 

therapy treatment/episode outset and reporting intervals 

GXXX8 

Walking & moving around functional limitation, projected goal status, at initial 

therapy treatment/outset and at discharge from therapy 

GXXX9 

Walking & moving around functional limitation, discharge status, at discharge 

from therapy/end of reporting on limitation 

GXX10 

Changing & Maintaining Body Position 

Changing & maintaining body position functional limitation, current status at 

time of initial therapy treatment/episode outset and reporting intervals 

GXX11 

Changing & maintaining body position functional limitation, projected goal 

status at initial therapy treatment/outset and at discharge from therapy 

GXX12 

Changing & maintaining body position functional limitation, discharge status 

at discharge from therapy/end of reporting on limitation 

GXX13 

Carrying, Moving & Handling Objects 

Carrying, moving & handling objects functional limitation, current status at 

time of initial therapy treatment/episode outset and reporting intervals 

GXX14 

Carrying, moving & handling objects functional limitation, projected goal 

status at initial therapy treatment/outset and at discharge from therapy 

GXX15 

Carrying, moving & handling objects functional limitation, discharge status at 

discharge from therapy/end of reporting on limitation 

GXX16 

Self Care (washing oneself, toileting, dressing, eating, drinking) 

Self care functional limitation, current status at time of initial therapy 

treatment/episode outset and reporting intervals 

GXX17 

Self care functional limitation, projected goal status at initial therapy 

treatment/outset and at discharge from therapy 

GXX18 

Self care functional limitation, discharge status at discharge from therapy/end 

of reporting on limitation 

GXX19 

Communication: Reception (spoken, nonverbal, sign language, written) 

Communication: Reception functional limitation, current status at time of 

initial therapy treatment/episode outset and reporting intervals 

GXX20 

Communication: Reception functional limitation, projected goal status at initial 

therapy treatment/outset and at discharge from therapy 

GXX21 

Communication: Reception functional limitation, discharge status at discharge 

from therapy/end of reporting on limitation 

GXX22 

Communication: Expression (speaking, nonverbal, sign language, writing) 
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Communication: Expression functional limitation, current status at time of 

initial therapy treatment/episode outset and reporting intervals 

GXX23 

Communication: Expression functional limitation, projected goal status at 

initial therapy treatment/outset and at discharge from therapy 

GXX24 

Communication: Expression functional limitation, discharge status at 

discharge from therapy/end of reporting on limitation 

GXX25 

The benefit of having these select G-code sets in addition to the general G-codes is that 

the data collected could be analyzed by specific diagnoses/conditions and categories of 

functional limitations. We believe that in order to develop an improved payment system for 

therapy services this type of information is needed. Moreover, expansion of these categorical Gcodes to encompass many more categories of functional limitations is essential. However, 

implementing specific G-codes for a select set of functional limitations could be a starting point. 

An initial data set could allow us to begin collecting the necessary data. It would also help us to 

evaluate how such a system works and make improvements before imposing requirements across 

the board. 

We seek input from therapists on categories of functional limitations, such as those 

described in this section. We specifically request comments regarding the following questions. 

Would data collected on categories of functional limitations provide more meaningful data on 

therapy services than that collected through use of the generic G-codes in our proposal? Should 

we choose to implement a system that is based on at least some select categories of functional 

limitation, which functional limitations should we collect data on in 2013? Is it more, less or the 

same burden to report on categories of functional limitations or generic ones? The categories of 

functional limitations described above are based on the ICF categories, but these ICF categories 

also have subcategories. Should we use subcategories for reporting? Are there specific 

conditions not covered by these ICF categories? Would we need to have G-codes for the same 

categories of secondary limitations? 

(5) Reporting Frequency 
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We propose to require this claims-based reporting in conjunction with the initial service 

at the outset of a therapy episode, at established intervals during treatment and at discharge. The 

number of G-codes required on a particular claim would vary from one to four, depending on the 

circumstances. Table 20 shows a graphic example of which codes are used for specified 

reporting. We would note that the example represents a therapy episode of care occurring over 

an extended time period. This example might be typical for a beneficiary receiving therapy for 

the late effects of a stroke. We chose to use an example with a much higher than average 

number of treatment days in order to show a greater variety of reporting scenarios. 

TABLE 20: Example Evaluation/Treatment Day 1 Begin Reporting Period #1 End Reporting Period #1 Begin Reporting Period #2 Claim for treatment days 

5 and 6 in Period #2 End Reporting Period #2 Begin Reporting Period #3 Discharge /End of reporting on Primary Functional Limitation End Reporting Period #3 

Primary Function Status 

GXXX1 – Current X X X X X 

GXXX2 – Goal X X X X 

GXXX3 – Discharge X 

Secondary Function 

GXXX4 – Current X X X X 

GXXX5 – Goal X X 

GXXX6 – Discharge 

No Functional Reporting Required 

GXXXX7 X 

● Outset. Under this proposal, the first reporting of G-codes and modifiers would occur 

when the outpatient therapy episode of care begins. This would typically be the date of service 

when the therapist furnishes the evaluation and develops the required plan of care for the 

beneficiary. At the outset, the therapist would use the G-codes and modifiers to report a current 
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status and a projected goal for the primary functional limitation. If a secondary functional 

limitation needs to be reported at this time, the same information would be reported using Gcodes and associated modifiers for the secondary functional limitation. 

● Every 10 Treatment Days or 30 Calendar Days, Whichever Is Less. We propose to 

require that the reporting frequency for G-codes and associated modifiers be once every 10 

treatment days or at least once during each 30 calendar days, whichever time period is shorter. 

The first treatment day for purposes of reporting would be the day that the initial visit takes 

place. The date the episode of care begins, typically at the evaluation, even when the therapist 

does not furnish a separately billable procedure in addition to the evaluation for this day, would 

be considered treatment day one, effectively beginning the count of treatment days or calendar 

days for the first reporting period. 

In calculating the 10 treatment days, a treatment day is defined as a calendar day in which 

treatment occurs resulting in a billable service. Often a treatment day and a therapy “session” or 

“visit” may be the same, but the two terms are not interchangeable. Infrequently, for example, a 

beneficiary might receive certain services twice a day – these two different sessions (or visits) in 

the same day are counted as one treatment day). 

On the claim for service on the 10th treatment day or the 30th calendar day after treatment 

day one, the therapist would only report GXXX1 and the appropriate modifier to show the 

beneficiary’s functional status at the end of this reporting period. If also reporting on a 

secondary functional limitation, GXXX4 and the appropriate modifier would be included as well. 

The next reporting period begins on the next treatment day, that is, the time period 

between the end of one reporting period and the next treatment day does not count towards the 

30 calendar day period. On the claim for services furnished on this date, the therapist would 

report both the G-code and modifier showing the current functional status at this time along with 
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the G-code and modifier reflecting the projected goal that was identified at the outset of the 

therapy episode. This process would continue until the beneficiary concludes the course of 

therapy treatment. 

On a claim for a service that does not require specific reporting of a G-code with modifier 

(that is, a claim for services between the first and the tenth day of service and that is less than 30 

days from the initial assessment), GXXX7 would be used. By using this code, the therapist 

would be confirming that the claim does not require specific functional limitation reporting. 

This is the only G-code that is reported without a severity modifier. 

The count of days, both treatment and calendar, for the second reporting period and any 

others thereafter, would begin on the first treatment day after the end of the previous reporting 

period. 

We selected the 10/30 frequency of reporting to be consistent with our timing 

requirements for progress reports. These timing requirements are included in the Documentation 

Requirements for Therapy Services (see Pub. 100-02, Chapter 15, Section 220.3, Subsection D). 

By making these reporting timeframes consistent with Medicare’s other requirements, therapists, 

who are already furnishing therapy services to Medicare outpatients, would have a familiar 

framework for successfully adopting our new reporting requirement. This should minimize the 

additional burden. In addition to reflecting the Medicare required documentation for progress 

reports, we believe that this simplifies the process and minimizes the new burden on practitioners 

since many therapy episodes would be completed by the 10th treatment day. In 2008, the average 

number of days in a therapy episode was nine treatment days for SLP, 11 treatment days for PT, 

and 12 treatment days for OT. When reporting on two functional limitations, the therapist would 

report the G-codes and modifiers for the second condition in the manner described above. In 

other words, at the end of the reporting period, two G-codes would be reported to show current 
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functional status – one for the primary (GXXX1) and one for the secondary (GXXX4) limitation. 

Similarly, at the beginning of the reporting period four G-codes would be reported. GXXX1 and 

GXXX4 would be used to report current status for the primary and secondary functional 

limitations, respectively; and, GXXX2 and GXXX5 would be used to report the goal status for 

the primary and secondary functional limitations, respectively. 

The reporting periods must be the same for both the primary and secondary functional 

limitation. The therapist can accomplish this by starting them at the same time or if the 

secondary functional limitation is added at some point in treatment, the primary functional 

limitation’s reporting period must be re-started by reporting GXXX1 and GXXX2 at the same 

time the new secondary functional limitation is added using GXXX4 and GXXX5. 

Further, for those therapy treatment episodes lasting longer periods of time, the periodic 

reporting of the G-codes and associated modifiers would reflect any progress that the beneficiary 

made toward the identified goal. In summary, we propose to require the reporting of G-codes 

and modifiers at episode outset (evaluation or initial visit), and once every 10th treatment day or 

at least every 30 calendar days, whichever time period is less. 

We believe it is important that the requirements for this reporting system be consistent 

with the requirements for documenting any progress in the medical record as specified in our 

manual. Given the current proposal for claims-based data collection, we believe it is an 

appropriate time to reassess the manual requirements. Toward this vein, we are seeking 

comment on whether it would be appropriate to modify the progress note requirement in the 

IOM to one based solely on the number of treatment days, such as six or ten. Should this 

modification be made, a corresponding change would be made in the reporting periods. We seek 

comments regarding clinical impact of such a change. 

● Discharge. In addition, we are proposing to require reporting of the G-code/modifier 
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functional data at the conclusion of treatment so that we have a complete set of data for the 

therapy episode of care. Requiring the reporting at discharge mirrors the IOM requirement of a 

discharge note or summary. This set of data would reveal any functional progress or 

improvement the beneficiary made toward the projected therapy goal during the entire therapy 

episode. Specifically, having information on the beneficiary’s functional status at the time of 

discharge shows whether or to what degree the projected therapy goal was met. 

To report the current status of the functional limitation at the time of discharge, the 

therapist would use GXXX3 and the appropriate modifier. Where there is a secondary functional 

limitation, GXXX6, along with its appropriate modifier, would also be reported. In addition, 

GXXX2, along with the modifier established at the outset of therapy, is used to report the 

projected goal status of the primary functional limitation. And, GXXX4 and its corresponding 

modifier is reported to show the projected goal status for the secondary functional limitation that 

was established at the outset of therapy. The imposition of this reporting requirement does not 

justify scheduling an additional, and perhaps medically unnecessary, final session in order to 

measure the beneficiary’s function for the sole purpose of reporting. 

Although collection of discharge data is important in achieving our goals, we recognize 

that data on functional status at the time therapy concludes is likely to be incomplete for some 

beneficiaries receiving outpatient therapy services. The DOTPA project has found this to be 

true. There are various reasons as to why the therapist would not be able to report functional 

status using G-codes and modifiers at the time therapy ends. Sometimes, beneficiaries may 

discontinue therapy without alerting their therapist of their intention to do so, simply because 

they feel better, they can no longer fit therapy into their work schedules, or their transportation is 

unavailable. Whatever the reason, there would be situations where the therapy ends without a 

discharge visit. In these situations, we would not require the reporting at discharge. However, 
CMS-1590-P 176 

we encourage therapists to include discharge reporting whenever possible on the final claims. 

For example, since the therapist is typically reassessing the beneficiary during the therapy 

sessions, the data critical to the severity/complexity of the functional measure may be available 

even when the final therapy session does not occur. In these instances, the G-codes and 

modifiers appropriate to discharge should be reported. 

We are particularly interested in how often the therapy community finds that 

beneficiaries discontinue therapy without the therapist knowing in advance that it is the last 

treatment session and other situations in which the discharge data would not be available for 

reporting. 

● Significant Change in Beneficiary Condition. We are proposing that, in addition to 

reporting at the intervals discussed above, the G-code/modifier measures would be required to be 

reported when a formal and medically necessary re-evaluation of the beneficiary results in an 

alteration of the goals in the beneficiary’s POC. This could result from new clinical findings, an 

added comorbidity, or a failure to respond to treatment described in the POC. This reporting 

affords the therapist the opportunity to explain a beneficiary’s failure to progress toward the 

initially established goal(s) and permits either the revision of the severity status of the existing 

goal or the establishment of a new goal or goals. The therapist would be required to begin a new 

reporting period when submitting a claim containing a CPT code for an evaluation or a reevaluation. These G-codes, along with the associated modifiers, could be used to show an 

increase in the severity of one or two functional limitations; or, they could be used to reflect the 

severity of newly identified functional limitations as delineated in the revised plan of care. 

(6) Documentation 

We propose to require that documentation of the information used for reporting under 

this system must be included in the beneficiary’s medical record. The therapist would need to 
CMS-1590-P 177 

track in the medical record the G-codes and the corresponding severity modifiers that were used 

to report the status of the functional limitations at the outset of the therapy episode, at the 

beginning and end of each reporting period, and at the time of discharge (or to report that the 

projected goal has been achieved and reporting on the particular functional limitation has ended). 

It is important to include this information in the record in order to create an auditable record and 

so that this record would also serve to improve the quality of data CMS collects as it will help 

the therapist keep track of assessment and treatment information for particular beneficiaries. 

For example, the therapist selects the functional limitation of “walking and moving” as 

the primary limitation and determines that at therapy outset the beneficiary has a 60 percent 

limitation and sets the goal to reduce the limitation to 5 percent. The therapist uses GXXX1-XH 

to report the current status of the functional impairment; and GXXX2-XB to report the goal. The 

therapist should note in the beneficiary’s medical record that the functional limitation is 

“walking and moving” and document the G-codes and severity modifiers used to report this

functional limitation on the claim for therapy services. 

(7) Claims Requirements 

Except for the addition of the proposed G-codes and modifiers, nothing in this proposal 

would modify other existing requirements for submission of therapy claims. For example, the 

therapy modifiers – GO, GP, and GN – are still required to indicate that the therapy services, for 

which the G-codes and modifiers are used to report function on, are furnished under a OT, PT, or 

SLP plan of care, respectively. 

Claims from institutional providers, which are submitted to the fiscal intermediaries (FIs) 

and A/B MACs, would require that a charge be included on the service line for each one of these 

G-codes in the series, GXXX1 - GXXX7. This charge would not be used for payment purposes 

and would not affect processing. Claims for professional services submitted to carriers and A/B 
CMS-1590-P 178 

MACs do not require that a charge be included for these nonpayable G-codes but reporting a 

charge for the nonpayable G-codes would not affect claims processing. 

Medicare does not process claims that do not include a billable service. As a result, 

reporting under this system would need to be included on the same claim as a furnished service 

that Medicare covers. 

(8) Implementation Date 

In accordance with section 3005(g) of the MCTRJCA, we propose to implement these 

data reporting requirements on January 1, 2013. We recognize that with electronic health 

records and electronic claims submission, therapists may encounter difficulty in including this 

new data on claims. To accommodate those that may experience operational or other difficulties 

with moving to this new reporting system and to assure smooth transition, we are proposing a 

testing period from January 1, 2013 until July 1, 2013. We would expect that all those billing for 

outpatient therapy services would take advantage of this testing period and begin attempting to 

report the new G-codes and modifiers as quickly as possible on or after January 1, 2013, in 

preparation for required reporting beginning on July 1, 2013. Taking advantage of this testing 

period would help to minimize potential problems after July 1, 2013, when claims without the 

appropriate G-codes and modifiers would be returned unpaid. 

(9) Compliance Required as a Condition for Payment and Regulatory Changes 

To implement the reporting system required by MCTRJCA and described above we are 

proposing to amend the regulations establishing the conditions for payment governing PT, OT, 

SLP, and CORFs to add a requirement that the claims include information on beneficiary 

functional limitations. In addition, we propose to amend the plan of care requirements set forth in 

the regulations for outpatient therapy services and CORFs to require that the therapy goals, 

which must be included in the POC, are consistent with the beneficiary function reporting on 
CMS-1590-P 179 

claims for services. 

Specifically, we propose to amend the regulations for outpatient OT, PT, and SLP 

(§410.59, §410.60, and §410.62, respectively) by adding a new paragraph (a)(4) to require that 

claims submitted for furnished services contain the information on beneficiary functional 

limitations as described in this rule. 

We also propose to amend the plan of care requirements set forth at §410.61(c) to require 

that the therapy goals, which must be included in the treatment plan, must be consistent with 

those reported on claims for services. This requirement is in addition to those already existing 

conditions for the POC 

To achieve consistency in the provision of PT, OT, and SLP services across settings, we 

propose to amend §410.105 to include the same requirements for these services furnished in 

CORFs. These proposed revisions would require that the goals in the treatment plan be 

consistent with the beneficiary function reported on claims for services and that claims submitted 

for furnished services contain specified information on beneficiary functional limitations, 

respectively. Respiratory therapy services furnished in CORFs are not subject to the reporting 

requirements, and therefore, these requirements would not apply to them. 

(10) Consulting with Relevant Stakeholders 

Section 3005(g) of the MCTRJCA requires us to consult with relevant stakeholders as we 

propose and implement this reporting system. We are meeting this requirement through the 

publication of this proposal, and specifically solicit public comment on the various aspects of our 

proposals. In addition, we plan to meet with key stakeholders and will discuss this issue in Open 

Door Forums over the course of the summer. 
CMS-1590-P 180 

H. Primary Care and Care Coordination 

In recent years, we have recognized primary care and care coordination as critical 

components in achieving better care for individuals, better health for individuals, and reduced 

expenditure growth. Accordingly, we have prioritized the development and implementation of a 

series of initiatives designed to ensure accurate payment for, and encourage long-term 

investment in, primary care and 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 

Federal Register on November 2, 2011 (76 FR 67802)). 

++ The testing of the Pioneer ACO model, designed for experienced health care 

organizations (described on the Center for Medicare and Medicaid Innovation’s (Innovation 

Center’s) website at http://innovations.cms.gov/initiatives/ACO/Pioneer/index.html). 

++ The testing of the Advance Payment ACO model, designed to support organizations 

participating in the Medicare Shared Savings Program (described on Innovation Center’s website 

at http://innovations.cms.gov/initiatives/ACO/Advance-Payment/index.html). 

● The Primary Care Incentive Payment (PCIP) Program (described on the CMS Website 

at http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeeSched/Downloads/PCIP-2011-Payments.pdf). 

● The patient-centered medical home model in the Multi-payer Advanced Primary Care 

Practice (MAPCP) Demonstration designed to test whether the quality and coordination of health 

care services are improved by making advanced primary care practices more broadly available. 

(described on the CMS Website at http://www.cms.gov/Medicare/DemonstrationProjects/DemoProjectsEvalRpts/downloads/mapcpdemo_Factsheet.pdf). The goal of the 
CMS-1590-P 181 

MAPCP demonstration is to take a multi-payer approach to creating more advanced primary care 

services or “medical homes” that utilize a team approach to care, while emphasizing prevention, 

health information technology, care coordination, and shared decision making. CMS will pay a 

monthly care management fee for Medicare fee-for-service beneficiaries receiving primary care 

from advanced primary care practices participating in the demonstration. The following states 

are participating in the MAPCP demonstration: Maine, Vermont, Rhode Island, New York, 

Pennsylvania, North Carolina, Michigan, and Minnesota. 1

● The Federally Qualified Health Center (FQHC) Advanced Primary Care Practice 

demonstration (described on the CMS Website at http://www.cms.gov/Medicare/DemonstrationProjects/DemoProjectsEvalRpts/downloads/mapcpdemo_Factsheet.pdf and Innovation Center’s 

website at http://innovations.cms.gov/initiatives/FQHCs/index.html). Participating FQHCs in the 

demonstration are expected to achieve National Committee for Quality Assurance (NCQA) 

Level 3 Patient-Centered Medical Home recognition by the end of the demonstration as well as 

help patients manage chronic conditions and actively coordinate care for patients. To help 

participating FQHCs make the needed investments in patient care and infrastructure, CMS is 

paying a monthly care management fee for each eligible Medicare fee-for-service beneficiary 

receiving primary care services. In addition, both CMS and the Health Resources Services 

Administration (HRSA) are providing technical assistance to FQHCs participating in the 

demonstration. 

● The Comprehensive Primary Care (CPC) initiative (described on the Innovation 

Center’s website at http://innovations.cms.gov/initiatives/Comprehensive-Primary-CareInitiative/index.html). The CPC initiative is a multi-payer initiative fostering collaboration 

between public and private health care payers to strengthen primary care in the following 

 

1

 More information about the MAPCP demonstration is available at http://www.cms.gov/Medicare/DemonstrationProjects/DemoProjectsEvalRpts/Medicare-Demonstrations-Items/CMS1230016.html. 
CMS-1590-P 182 

markets: Arkansas, Colorado, New Jersey, New York in the Capital-District-Hudson Valley 

Region, Ohio and Kentucky in the Cincinnati-Dayton Region, Oklahoma in the Greater Tulsa 

Region, and Oregon. CMS pays a monthly care management fee to selected primary care 

practices on behalf of their fee-for-service Medicare beneficiaries and in years 2-4 of the 

initiative, each practice has the potential to share in savings to the Medicare program. 

In coordination with these initiatives, we also continue to explore other potential 

refinements to the PFS that would appropriately value primary care and care coordination within 

Medicare’s statutory structure for fee-for-service physician payment and quality reporting. We 

believe that improvements in payment for primary care and recognizing care coordination 

initiatives are particularly important as EHR technology diffuses and improves the ability of 

physicians and other providers of health care to work together to improve patient care. We view 

these potential refinements to the PFS as part of a broader strategy that relies on input and 

information gathered from the initiatives described above, research and demonstrations from 

other public and private stakeholders, the work of all parties involved in the potentially 

misvalued code initiative, and from the public at large. 

The annual PFS notice and comment rulemaking process provides an important avenue 

for interested parties to provide input on discrete proposals intended to achieve these goals. 

Should any of these discrete proposals become final policy, we would expect many of them to be 

short-term payment strategies that would be modified and/or revised to be consistent with 

broader primary care and care management and coordination services if the agency decides to 

pursue payment for a broader set of management and coordination services in future rulemaking. 

In the CY 2012 PFS proposed rule (76 FR 42793 through 42794), we initiated a 

discussion to gather information about how primary care services have evolved to focus on 

preventing and managing chronic disease. We also proposed to review evaluation and 
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management (E/M) services as potentially misvalued and suggested that the American Medical 

Association Relative (Value) Update Committee (AMA RUC) might consider changes in the 

practice of chronic disease management and care coordination as key reason for undertaking this 

review. In the CY 2012 PFS final rule with comment period, we did not finalize our proposal to 

review E/M codes due to consensus from an overwhelming majority of commenters that a review 

of E/M services using our current processes could not appropriately value the evolving practice 

of chronic care coordination, and therefore, would not accomplish the agency’s goal of paying 

appropriately for primary care services. We stated that we would continue to consider ongoing 

research projects, demonstrations, and the numerous policy alternatives suggested by 

commenters. In addition, in the CY 2012 PFS proposed rule (76 FR 42917 through 42920), we 

initiated a public discussion regarding payments for post-discharge care management services. 

We sought broad public comment on how to further improve care management for a 

beneficiary’s transition from the hospital to the community setting within the existing statutory 

structure for physician payment and quality reporting. We specifically discussed how post 

discharge care management services are coded and valued under the current E/M coding 

structure, and we requested public comment. 

The physician community responded that comprehensive care coordination services are 

not adequately represented in the descriptions of, or payments for, office/outpatient E/M 

services. The American Medical Association (AMA) and the American Academy of Family 

Physicians (AAFP) created workgroups to consider new options for coding and payment for 

primary care services. The AAFP Task Force recommended that CMS create new primary care 

E/M codes and pay separately for non-face-to-face E/M Current Procedural Terminology (CPT) 

codes. (A summary of these recommendations is available at 

http://www.aafp.org/online/en/home/publications/news/news-now/inside-
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aafp/20120314cmsrecommendations.html.) The AMA workgroup, Chronic Care Coordination 

Workgroup (C3W), is developing codes to describe care transition and care coordination 

activities. (Several workgroup meeting minutes and other related items are available at 

http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-yourpractice/coding-billing-insurance/medicare/care-coordination.page) We are continuing to 

monitor the progress of this workgroup and look forward to receiving its final recommendations. 

For this CY 2013 PFS proposed rule, we have decided to proceed with a proposal to refine PFS 

payment for post discharge care management services. We also include a discussion of how we 

could incorporate the idea of advanced primary care through practices certified as medical homes 

in the FFS setting. In developing the proposal and discussion described below, we have 

thoroughly considered documented concerns regarding Medicare payment for non-face-to-face 

elements of E/M services that are crucial to care coordination. We will continue to consider 

other enhancements to payment for primary care services and complex chronic care coordination 

services, and we may make further proposals to improve payment mechanisms and foster quality 

care for these and similar services in future rulemaking. 

Under current PFS policy, care coordination is a component of E/M services which are 

generally reported using E/M CPT codes. The pre- and post-encounter non face-to-face care 

management work is included in calculating the total work for the typical E/M services, and the 

total work for the typical service is used to develop RVUs for the E/M services. In the CY 2012 

PFS proposed rule, we highlighted some of the E/M services that include substantial care 

coordination work. Specifically, we noted that the vignettes that describe a typical service for 

mid-level office/outpatient services (CPT codes 99203 and 99213) include providing care 

coordination, communication, and other necessary care management related to the office visit in 

the post-service work. We also highlighted vignettes that describe a typical service for hospital 
CMS-1590-P 185 

discharge day management (CPT codes 99238 and 99239), which include providing care 

coordination, communication, and other necessary management related to the hospitalization in 

the post-service work. 

As we have indicated many times in prior rulemaking, the payment for non-face-to-face 

care management services is bundled into the payment for face-to-face E/M visits. Moreover, 

Medicare does not pay for services that are furnished to parties other than the beneficiary and 

which Medicare does not cover, for example, communication with caregivers. Accordingly, we 

do not pay separately for CPT codes for telephone calls, medical team conferences, prolonged 

services without patient contact, or anticoagulation management services. 

However, we continue to hear concerns from the physician community that the care 

coordination included in many of the E/M services, such as office visits, does not adequately 

describe the non-face-to-face care management work involved in primary care. Because the 

current E/M office/outpatient visit CPT codes were designed to support all office visits and 

reflect an overall orientation toward episodic treatment, we agree that these E/M codes may not 

reflect all the services and resources required to furnish comprehensive, coordinated care 

management for certain categories of beneficiaries such as those who are returning to a 

community setting following discharge from a hospital or SNF stay. We are therefore 

considering new options to recognize the additional resources typically involved in furnishing 

coordinated care to particular types of beneficiaries. 

As described below, we are proposing to address the significant non-face-to-face work 

involved in coordinating services for a beneficiary after discharge from a hospital or skilled 

nursing facility (SNF). Specifically, we propose to create a HCPCS G-code to describe care 

management involving the transition of a beneficiary from care furnished by a treating physician 

during a hospital stay (inpatient, outpatient observation services, or outpatient partial 
CMS-1590-P 186 

hospitalization), SNF stay, or community mental health center (CMHC) partial hospitalization 

program to care furnished by the beneficiary’s primary physician in the community. We 

consider this proposal to be part of a multiple year strategy exploring the best means to 

encourage care coordination services. Furthermore, in the interest of encouraging 

comprehensive primary care services furnished in advanced primary care practices, we have 

included a discussion regarding how care furnished in these settings might be incorporated into 

the current fee-for-service structure of the PFS We look forward to continued development of 

these ideas through current research and demonstration projects, experience with ACOs and 

other programs, and further discourse on these issues with stakeholders. 

1. Hospital, SNF, or CMHC Post-Discharge Care Management 

a. Background 

Care management involving the transition of a beneficiary from care furnished by a 

treating physician during a hospital, SNF, or CMHC stay to the beneficiary’s primary physician 

in the community can avoid adverse events such as readmissions or subsequent illnesses, 

improve beneficiary outcomes, and avoid a financial burden on the health care system. 

Successful efforts to improve hospital discharge care management and care transitions could 

improve the quality of care while simultaneously decreasing costs. 

Currently, there are several agency initiatives aimed at hospital and community-based 

organizations. In April 2011, HHS launched the Partnership for Patients, a national publicprivate patient safety initiative for which more than 6,000 organizations—including physician 

and nurses’ organizations, consumer groups, employers and over 3,000 hospitals—have pledged 

to help achieve the Partnership’s goals of reducing hospital complications and improving care 

transitions. (More information on this initiative is available at 

http://innovations.cms.gov/initiatives/partnership-for-patients/index.html.) The Partnership for 
CMS-1590-P 187 

Patients includes the Community-based Care Transitions Program, created by section 3026 of the 

Affordable Care Act, which provides funding to community-based organizations partnering with 

eligible hospitals to coordinate a continuum of post-acute care to test models for improving care 

transitions for high risk Medicare beneficiaries. 

 Section 1886(q) of the Act (as added by section 3025 of the Affordable Care Act) directs 

the Secretary to establish a Hospital Readmissions Reduction Program, beginning in FY 2013, 

for certain potentially preventable Medicare inpatient hospital readmissions covering three 

conditions: heart attack; pneumonia; and congestive heart failure. Beginning in FY 2015, the 

number of applicable conditions can be expanded beyond the initial three conditions. Under this 

program, a portion of Medicare’s payment amounts for inpatient services to certain hospitals will 

be reduced by an adjustment factor based the hospital’s excess Medicare readmissions. In the 

FY 2012 IPPS final rule (76 FR 51662-51676), we provided an overview of the Hospital 

Readmission Reduction program and finalized policies regarding selection of applicable 

conditions, definition of “readmissions,” measures of the applicable conditions chosen for 

readmissions, methodology for calculating the excess readmissions ratio, public reporting of 

readmission data, and definition of applicable period. In the FY2013 IPPS proposed rule (77 FR 

27955-27968), we made proposals regarding the base operating DRG payment amount, the 

adjustment factor, aggregate payments for excess readmissions, and the hospitals that would be 

included in the program. 

In its 2007 Report to Congress: Promoting Greater Efficiency in Medicare, MedPAC 

found that, in 2005, 17.6 percent of admissions resulted in readmissions within 30 days of 

discharge, accounting for $15 billion in spending. MedPAC estimated that 76 percent of the 30 

day readmissions were potentially preventable, resulting in $12 billion in spending. In the same 

report, MedPAC also found that the rate of potentially avoidable rehospitalizations after 
CMS-1590-P 188 

discharges from skilled nursing facilities was 17.5 percent in 2004 (an increase of 2.8 percentage 

points from 2000.) MedPAC noted: “We focus on the hospital’s role but recognize that other 

types of providers, including physicians and various post-acute care providers, can be 

instrumental in avoiding readmissions...[C]ommunity physicians and post-acute care providers 

receiving the patient may not be sufficiently informed about the patient’s care needs and history 

to enable effective care.” We agree with MedPAC that primary care physicians and practitioners 

play a key role in post-acute care and reducing hospital readmissions. 

In the CY 2012 PFS proposed rule (76 FR 42917 through 42920), we initiated a public 

discussion regarding payments for post-discharge care coordination services. We sought broad 

public comment on how to further improve physician care coordination within the statutory 

structure for physician payment and quality reporting, particularly for a beneficiary’s transition 

from the hospital to the community. As noted above, we also proposed to review E/M services 

as potentially misvalued and suggested that the AMA RUC might consider chronic disease 

management and care coordination in its review (76 FR 42793). While the commenters agreed 

that care coordination would lead to better care for beneficiaries, they believed this care would 

be better described by new codes, and not the current E/M codes. 

b. Hospital and SNF Discharge Services 

We believe that the successful transition of a beneficiary from care furnished by a 

hospitalist physician to care furnished by the beneficiary’s primary physician or qualified 

nonphysician practitioner could avoid adverse events such as readmissions or subsequent 

illnesses, improve beneficiary outcomes, and avoid a financial burden on the health care system. 

We also believe that the current hospital discharge management codes (CPT codes 99238 

and 99239) and nursing facility discharge services (CPT codes 99315 and 99316) adequately 

capture the care coordination services required to discharge a beneficiary from hospital or skilled 
CMS-1590-P 189 

nursing facility care. The work relative values for those discharge management services include 

a number of pre-, post-, and intra-care coordination activities. For example, the hospital 

discharge management codes include the following pre-, intra-, and post- service activities 

relating to care coordination: 

Pre-service care coordination activities include: 

● Communicate with other professionals and with patient or patient's family. 

Intra-service care coordination activities include: 

● Discuss aftercare treatment with the patient, family and other healthcare professionals; 

● Provide care coordination for the transition including instructions for aftercare to 

caregivers; 

● Order/arrange for post discharge follow-up professional services and testing; and 

● Inform the primary care or referring physician or qualified nonphysician practitioner 

of discharge plans. 

Post-service care coordination activities include: 

● Provide necessary care coordination, telephonic or electronic communication 

assistance, and other necessary management related to this hospitalization; and 

● Revise treatment plan(s) and communicate with patient and/or caregiver, as necessary. 

The hospital and nursing facility discharge management codes also include a number of other 

pre-, intra and post-service activities. 

 Because these activities are critical to successfully avoiding readmissions, we seek 

comment about the best ways to ensure that all the activities of the discharge day management 

codes for hospital and nursing facility discharge, including the care coordination activities, are 

understood and furnished by the physicians or qualified nonphysician practitioners who bill for 

these services. Potential ways could include physician education or MEDLEARN articles. 
CMS-1590-P 190 

c. Defining Post-Discharge Transitional Care Management Services 

While we believe that current hospital and nursing facility discharge management service 

codes adequately capture the care management activities involved with discharging a beneficiary 

from a hospital or skilled nursing facility, we do not believe that current E/M office or other 

outpatient visit CPT codes appropriately describe comparable care management work of the 

community physician or qualified nonphysician practitioner coordinating care for the beneficiary 

post-discharge. This is because the E/M codes represent the typical outpatient office visit and do 

not capture or reflect the significant care coordination activities that need to occur when a patient 

transitions from institutional to community-based care. We believe that the work of the 

discharging physician or qualified nonphysician practitioner should be complemented by 

corresponding work of a receiving physician or qualified nonphysician practitioner in the 

community in order to ensure better continuity of care through establishing or revising a plan of 

care for the beneficiary after discharge. We acknowledge that many, if not most, physicians or 

qualified nonphysician practitioners caring for beneficiaries following a hospital or nursing 

facility discharge have been furnishing coordinated care and reporting office or other outpatient 

CPT codes. However, we agree with commenters to the CY 2012 proposed and final rules that 

the services described by current E/M office or other outpatient CPT codes 99201 through 99215 

may not appropriately capture the significant coordination services involved in post-discharge 

care. 

We are proposing to create a HCPCS G-code that specifically describes post-discharge 

transitional care management services. The code would describe all non-face-to-face services 

related to the transitional care management furnished by the community physician or qualified 

nonphysician practitioner within 30 calendar days following the date of discharge from an 

inpatient acute care hospital, psychiatric hospital, long-term care hospital, skilled nursing 
CMS-1590-P 191 

facility, and inpatient rehabilitation facility; hospital outpatient for observation services or partial 

hospitalization services; and a partial hospitalization program at a CMHC to community-based 

care. The post-discharge transitional care management service includes non-face-to-face care 

management services furnished by clinical staff member(s) or office-based case manager(s) 

under the supervision of the community physician or qualified nonphysician practitioner. We use 

the term community physician and practitioner in this discussion to refer to the community-based 

physician managing and coordinating a beneficiary’s care in the post-discharge period. We 

anticipate that most community physicians will be primary care physicians and practitioners. We 

have based the concept of this proposal, in part, on our policy for care plan oversight services. 

We currently pay physicians for the non face-to-face care plan oversight services furnished for 

patients under care of home health agencies or hospices. These patients require complex and 

multidisciplinary care modalities that involve: regular physician development and/or revision of 

care plans, subsequent reports of patient status, review of laboratory and other studies, 

communication with other health professionals not employed in the same practice who are 

involved in the patient’s care, integration of new information into the care plan, and/or 

adjustment of medical therapy. Physicians providing these services bill HCPCS codes G0181 

(Physician supervision of a patient receiving Medicare-covered services provided by a 

participating home health agency (patient not present) requiring complex and multidisciplinary 

care modalities involving regular physician development and/or revision of care plans, review of 

subsequent reports of patient status, review of laboratory and other studies, communication 

(including telephone calls) with other health care professionals involved in the patient’s care, 

integration of new information into the medical treatment plan and/or adjustment of medical 

therapy, within a calendar month, 30 minutes or more), or G0182 (Physician supervision of a 

patient under a Medicare-approved hospice (patient not present) requiring complex and 
CMS-1590-P 192 

multidisciplinary care modalities involving regular physician development and/or revision of 

care plans, review of subsequent reports of patient status, review of laboratory and other studies, 

communication (including telephone calls) with other health care professionals involved in the 

patient’s care, integration of new information into the medical treatment plan and/or adjustment 

of medical therapy, within a calendar month, 30 minutes or more). (See the Medicare benefit 

manual, 100-02, Chapter 15,Section 30 for detailed description of these services.)

For CY 2013, we are proposing to create a new code to describe post-discharge 

transitional care management. This service would include: 

● Assuming responsibility for the beneficiary’s care without a gap. 

++ Obtaining and reviewing the discharge summary. 

++ Reviewing diagnostic tests and treatments. 

++ Updating of the patient’s medical record based on a discharge summary to 

incorporate changes in health conditions and on-going treatments related to the hospital or 

nursing home stay within 14 business days of the discharge. 

● Establishing or adjusting a plan of care to reflect required and indicated elements, 

particularly in light of the services furnished during the stay at the specified facility and to reflect 

result of communication with beneficiary. 

++ An assessment of the patient’s health status, medical needs, functional status, pain 

control, and psychosocial needs following the discharge. 

● Communication (direct contact, telephone, electronic) with the beneficiary and/or 

caregiver, including education of patient and/or caregiver within 2 business days of discharge 

based on a review of the discharge summary and other available information such as diagnostic 

test results, including each of the following tasks: 

++ An assessment of the patient’s or caregiver’s understanding of the medication 
CMS-1590-P 193 

regimen as well as education to reconcile the medication regimen differences between the preand post-hospital, CMHC, or SNF stay. 

++ Education of the patient or caregiver regarding the on-going care plan and the 

potential complications that should be anticipated and how they should be addressed if they 

arise. 

++ Assessment of the need for and assistance in establishing or re-establishing necessary 

home and community based resources. 

++ Addressing the patient’s medical and psychosocial issues, and medication 

reconciliation and management. 

When indicated for a specific patient, the post-discharge transitional care service would 

also include: 

● Communication with other health care professionals who will (re)assume care of the 

beneficiary, education of patient, family, guardian, and/or caregiver. 

● Assessment of the need for and assistance in coordinating follow up visits with health 

care providers and other necessary services in the community. 

● Establishment or reestablishment of needed community resources. 

● Assistance in scheduling any required follow-up with community providers and 

services. 

The post-discharge transitional care services HCPCS G-code we are proposing would be 

used by the community physician or qualified nonphysician practitioner to report the services 

furnished in the community to ensure the coordination and continuity of care for patients 

discharged from a hospital (inpatient stay, outpatient observation, or outpatient partial 

hospitalization), SNF stay, or CMHC. The post-discharge transitional care service would 

parallel the discharge day management service for the community physician or qualified 
CMS-1590-P 194 

nonphysician practitioner and complement the E/M office/outpatient visit CPT codes. 

The post-discharge transitional care service would support the patient’s physical and 

psychosocial health. In our recent Decision Memorandum for Screening for Depression in 

Adults, CAG-00425N, we noted that depression in older adults occurs in a complex psychosocial 

and medical context and that, currently, we believe opportunities are missed to improve mental 

health and general medical outcomes when mental illness is under-recognized and undertreated 

in primary care settings. We wish to emphasize the equal importance of the patient’s mental 

health to the patient’s physical condition to successful re-entry into the community. 

We propose that the post-discharge transitional care service HCPCS G-code would be 

used to report physician or qualifying nonphysician practitioner services for a patient who’s 

medical and/or psychosocial problems require moderate or high complexity medical decision 

making during transitions in care from hospital (inpatient stay, outpatient observation, and partial 

hospitalization), SNF stay, or CMHC settings to community-based care. Moderate and high 

complexity medical decision making are defined in the Evaluation and Management Guidelines. 

In general, moderate complexity medical decision-making includes multiple diagnoses or 

management options, moderate complexity and amount of data to be review, a moderate amount 

and/or complexity of data to be reviewed; and a moderate risk of significant complications, 

morbidity, and/or mortality. High complexity decision-making includes an extensive number of 

diagnoses or management options, an extensive amount and/or complexity of data to be 

reviewed, and high risk of significant complications, morbidity, and/or mortality (See Evaluation 

and Management Services Guide, Centers for Medicare & Medicaid Services, December 2010.) 

We propose that the post-discharge transitional care HCPCS code (GXXX1) would be payable 

only once in the 30 days following a discharge, per patient per discharge, to a single community 

physician or qualified nonphysician practitioner (or group practice) who assumes responsibility 
CMS-1590-P 195 

for the patient’s post-discharge transitional care management. The service would be billable 

only at 30 days post discharge or thereafter. The post-discharge transitional care management 

service would be distinct from services furnished by the discharging physician or qualified 

nonphysician practitioner reporting CPT codes 99238 (Hospital discharge day management, 30 

minutes or less); 99239 (Hospital discharge day management, more than 30 minutes) ; 99217 

(Observation care discharge day management); or Observation or Inpatient Care services, CPT 

codes 99234 -99236; as appropriate. 

We propose to pay the first claim that we receive for the beneficiary at 30 days after 

discharge. Given the elements of the service and the short window of time following a discharge 

during which a physician or qualifying nonphysician practitioner will need to perform several 

tasks on behalf of a beneficiary, we believe it is unlikely that two or more physicians or 

practitioners would have had a face-to-face E/M contact with the beneficiary in the specified 

window of 30 days prior or14 days post discharge and have furnished the proposed postdischarge transitional care management services listed above. Therefore, we do not believe it is 

necessary to take further steps to identify a beneficiary’s community physician or qualified 

nonphysician practitioner who furnishes the post-discharge transitional care management 

services. We propose to pay only one claim for the post-discharge transitional care GXXX1 

billed per beneficiary at the conclusion of the 30 day post-discharge period. Post-discharge 

transitional care management relating to any subsequent discharges for a beneficiary in the same 

30-day period would be included in the single payment. Practitioners billing this post-discharge 

transitional care code accept responsibility for managing and coordinating the beneficiary’s care 

over the first 30 days after discharge. Although we currently envision billing happening as it 

does for most services, after the conclusion of the service, we welcome comment on whether in 

this case there would be merit to allowing billing for the code to occur at the time the plan of 
CMS-1590-P 196 

care is established. 

We have explicitly constructed this proposal as a payment for non face-to-face postdischarge transitional care management services separate from payment for E/M or other medical 

visits. However, we believe that it is important to ensure that the community physician or 

qualified nonphysician practitioner furnishing post-discharge transitional care management either 

have or establish a relationship with the patient. As such, we propose that the community 

physician or qualified nonphysician practitioner reporting post-discharge transitional care 

management GXXX1 should already have a relationship with the beneficiary, or establish one 

soon after discharge, prior to furnishing transitional care management and billing this code. 

Therefore, we propose that the community physician or qualified nonphysician practitioner 

reporting a transitional care management HCPCS G-code must have billed an E/M visit for that 

patient within 30 days prior to the hospital discharge (the start of post-discharge transitional care 

management period), or must conduct an E/M office/outpatient visit (99201 to 99215) within the 

first 14 days of the 30-day post-discharge period of transitional care management services. The 

E/M visit would be separately billed. 

While we are proposing that the post-discharge transitional care management code would 

not include a face-to-face visit, and that physicians or qualified nonphysician practitioners would 

bill and be paid for this care management service separately from a medical visit, we are seeking 

comments about whether we should require a face-to-face visit when billing for the postdischarge transitional care management service. We are also seeking comments regarding how 

we might incorporate such a required visit on the same day into the payment for the proposed 

code. We considered several reasons for requiring a face-to-face visit on the same day. We 

wondered whether, with a face-to-face visit immediately after discharge, the plan of care would 

be more accurate given that the patient’s medical or psychosocial condition may have changed 
CMS-1590-P 197 

from the time the practitioner last met with the patient and the practitioner could better develop a 

plan of care through an in-person visit and discussion. We also wondered whether beneficiaries 

would understand their coinsurance liability for the post-discharge transitional care service when 

they did not visit the physician’s or qualified nonphysician practitioner’s office. On the other 

hand, we have contemplated several scenarios where it is not possible for a beneficiary to get to 

the physician’s or qualified nonphysician practitioner’s office and welcome comment on whether 

an exception process would be appropriate if we were to finalize a same day face-to-face visit as 

a requirement for billing the post-discharge transitional care management code. 

The proposed post-discharge transitional care HCPCS G-code would be described as 

follows: 

GXXX1 Post-discharge transitional care management with the following 

required elements: 

● Communication (direct contact, telephone, electronic) with the patient or caregiver 

within 2 business days of discharge. 

● Medical decision making of moderate or high complexity during the service period. 

• To be eligible to bill the service, physicians or qualified nonphysician practitioners 

must have had a face-to-face E/M visit with the patient in the 30 days prior to the transition in 

care or within 14 business days following the transition in care. 

We contemplated establishing a requirement that post-discharge transitional care management be 

furnished by a physician or qualified nonphysician practitioner or other clinical staff in the 

practice who are qualified to assist beneficiaries in managing post-transition changes in 

conditions and treatments. We welcome public comment on whether this would be an 

appropriate requirement for GXXX1. 

We propose that a physician or qualified nonphysician practitioner who bills for 
CMS-1590-P 198 

discharge management during the time period covered by the transitional care management 

services code may not also bill for HCPCS code GXXX1. The CPT discharge management 

codes are 99217, 99234-99236, 99238-99239, 99281-99285, or 99315-99316, home health care 

plan oversight services (HCPCS code G0181), or hospice care plan oversight services (HCPCS 

code G0182) . We believe these codes describe care management services for which Medicare 

makes separate payment and should not be billed in conjunction with GXXX1, which is a 

comprehensive post-discharge transitional care management service. Further, we propose that a 

physician or qualified nonphysician practitioner billing for a procedure with a 10- or 90-day 

global period would not also bill HCPCS code GXXX1 in conjunction with that procedure 

because any follow-up care management would be included in the post-operative portion of the 

global period. Many of the global surgical packages include discharge management codes. We 

believe that any physician or qualified nonphysician practitioner billing separately for the 

discharge management code that also is the community physician or nonphysician practitioner 

for the beneficiary would be paid for post-discharge transitional care management through the 

discharge management code. 

 We are making this proposal to provide a separate reporting mechanism to the 

community physician for these services in the context of the broader HHS and CMS multi-year 

strategy to recognize and support primary care and care management. Should any of these 

discrete proposals, like this one, become final policy, they may be short-term payment strategies 

that would be modified and/or revised to be consistent with broader primary care and care 

management and coordination services if the agency decides to pursue payment for a broader set 

of management and coordination services in future rulemaking. We would also note that this 

proposal dovetails with our discussion under section III.J. of this proposed rule on the Valuebased Payment Modifier and Physician Feedback Reporting Program which discusses hospital 
CMS-1590-P 199 

admission measures and a readmission measure as outcome measures for the proposed valuebased payment modifier adjustment beginning in CY 2105. 

c. Proposed Payment for Post-Discharge Transitional Care Management Service 

 To establish a physician work relative value unit (RVU) for the proposed post-discharge 

transitional care management, HCPCS code GXXX1, we compared GXXX1 with CPT code 

99238 (Hospital discharge day management; 30 minutes or less) (work RVU = 1.28). We 

recognize that, unlike CPT code 99238, HCPCS code GXXX1 is not a face-to-face visit. 

However, we believe that the physician time and intensity involved in post-discharge community 

care management is most equivalent to CPT code 99238 which, like the proposed new G-code, 

involves a significant number of care management services. Therefore, we are proposing a work 

RVU of 1.28 for HCPCS code GXXX1 for CY 2013. We also are proposing the following 

physician times: 8 minutes pre-evaluation; 20 minutes intra-service; and 10 minutes immediate 

post-service. The physician time file associated with this PFS proposed rule is available on the 

CMS Website in the Downloads section for the CY 2013 PFS proposed rule at 

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

In addition, we are proposing to crosswalk the clinical labor inputs from CPT code 

99214 (Level 4 established patient office or other outpatient visit) to the post-discharge 

transitional care code. The proposed CY 2013 direct PE input database reflects these inputs and 

is available on the CMS Website under the supporting data files for the CY 2013 PFS proposed 

rule with comment period at http://www.cms.gov/PhysicianFeeSched/. The proposed PE RVUs 

included in Addendum B to this proposed rule reflect the RVUs that result from application of 

this proposal. 

For malpractice expense, we are proposing a malpractice crosswalk of CPT code 99214 

for HCPCS code GXXX1 for CY 2013. We believe the malpractice risk factor for CPT code 
CMS-1590-P 200 

99214 appropriately reflects the relative malpractice risk associated with furnishing HCPCS code 

GXXX1. The malpractice RVUs included in Addendum B to this proposed rule reflect the 

RVUs that result from the application of this proposal. 

We note that as with other services paid under the PFS the 20 percent beneficiary 

coinsurance would apply to the post-discharge transitional care management service as would the 

Part B deductible. 

For BN calculations, we estimated that physicians or qualified nonphysician practitioners 

would provide post-discharge transitional care management services for 10 million discharges in 

CY 2013. This number roughly considers the total number of hospital inpatient and SNF 

discharges, hospital outpatient observation services and partial hospitalization patients that may 

require with moderate to high complexity decision-making. 

For purposes of the Primary Care Incentive Payment Program (PCIP), we are proposing 

to exclude the post discharge transitional care management services from the total allowed 

charges used in the denominator calculation to determine whether a physician is a primary care 

practitioner. Under section 1833(x) of the statute the PCIP provides a 10 percent incentive 

payment for primary care services within a specific range of E/M services when furnished by a 

primary care practitioner. Specific physician specialties and qualified nonphysician practitioners 

can qualify as primary care practitioners if 60 percent of their PFS allowed charges are primary 

care services. As we explained in the CY 2011 PFS final rule (75 FR 73435-73436), we do not 

believe the statute authorizes us to add codes (additional services) to the definition of primary 

care services. However, in order to avoid inadvertently disqualifying community primary care 

physicians who follow their patients into the hospital setting, we finalized a policy to remove 

allowed charges for certain E/M services furnished to hospital inpatients and outpatients from the 

total allowed charges in the PCIP primary care percentage calculation. 
CMS-1590-P 201 

We believe that the proposed transitional care management code should be treated in the 

same manner as those services for the purposes of PCIP because post-discharge transitional care 

management services are a complement in the community setting to the hospital-based discharge 

day management services already excluded from the PCIP denominator. Similar to the codes 

already excluded from the PCIP denominator, we are concerned that inclusion of the transitional 

care management code in the denominator of the primary care percentage calculation could 

produce unwarranted bias against “true primary care practitioners” who are involved in 

furnishing post-discharge care to their patients. Therefore, while physicians and qualified 

nonphysician practitioners who furnish transitional care management would not receive an 

additional incentive payment under the PCIP for the service itself (because it is not considered a 

“primary care service” for purposes of the PCIP), the allowed charges for transitional care 

management would not be included in the denominator when calculating a physician’s or 

practitioner’s percent of allowed charges that were primary care services for purposes of the 

PCIP. 

2. Primary Care Services Furnished in Advanced Primary Care Practices 

a. Background 

 As we have discussed above, we are committed to considering new options and 

developing future proposals for payment of primary care services under the MPFS. Such options 

would promote comprehensive and continuous assessment, care management, and attention to 

preventive services that constitute effective primary care by establishing appropriate payment 

when physicians furnish such services. One method for ensuring that any targeted payment for 

primary care services would constitute a minimum level of care coordination and continuous 

assessment under the MPFS would be to pay physicians for services furnished in an “advanced 

primary care practice” that has implemented a medical home model supporting patient-specific 
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care. The medical home model has been the subject of extensive study in medical literature. 

Since 2007, the AMA, American Academy of Family Physicians (AAFP), the American 

Academy of Pediatrics (AAP), the American College of Physicians (ACP), and the American 

Osteopathic Association (AOA), and many other physician organizations have also endorsed 

“Joint Principles of the Patient-Centered Medical Home.” In February 2011, the AAFP, the 

AAP, the ACP, and AOA also published formal “Guidelines for Patient-Centered Medical 

Home (PCMH) Recognition and Accreditation Programs” to develop and promote the concept 

and practice of the PCMH. (These guidelines are available at 

http://www.aafp.org/online/etc/medialib/aafp_org/documents/membership/pcmh/pcmhtools/pcm

hguidelines.Par.0001.File.dat/GuidelinesPCMHRecognitionAccreditationPrograms.pdf.) As we 

have discussed above, the Innovation Center has been conducting a several initiatives based on 

the medical home concept. 

 The medical home concept emphasizes establishing an extensive infrastructure requiring 

both capital investments and new staffing, along with sophisticated processes, to support 

continuous and coordinated care with an emphasis on prevention and early diagnosis and 

treatment. The literature, reports, and guidelines dealing with the medical home concept define 

the requisite elements or functions that constitute this infrastructure and processes in various 

ways. For example, the Innovation Center’s CPC initiative identified a set of five 

“comprehensive primary care functions,” which form the service delivery model being tested and 

the required framework for practice transformation under the CPC initiative. We believe these 

five “comprehensive primary care functions” provide an appropriate starting point for discussing 

the incorporation of the comprehensive primary care services delivered in advanced primary care 

practices (practices implementing a medical home model) into the MPFS: 

1. Risk-stratified Care Management 
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One of the hallmarks of comprehensive primary care is the provision of intensive care 

management for high-risk, high-need, high-cost patients. Providers must provide routine, 

systematic assessment of all patients to identify and predict which patients need additional 

interventions. In consultation with their patients, they should create a plan of care to assure care 

that is provided is congruent with patient choices and values. Once patient needs, including 

social needs and functional deficits, have been identified, they should be systematically 

addressed. Markers of success include policies and procedures describing routine risk 

assessment and the presence of appropriate care plans informed by the risk assessment. 

2. Access and Continuity 

Health providers who know the patient should be accessible when a patient needs care. 

Providers must have access to patient data even when the office is closed so they can continue to 

participate in care decisions with their patients. Patients need access to the patient care team 

24/7. Every patient is assigned to a designated provider or care team with whom they are able to 

get successive appointments. Markers of success include care continuity and availability of the 

EHR when the office is closed. 

3. Planned Care for Chronic Conditions and Preventive Care 

Primary care must be proactive. Practitioners must systematically assess all patients to 

determine his or her needs (one way would be through the annual wellness visit2

) and provide 

proactive, appropriate care based on that assessment. Pharmaceutical management, including 

medication reconciliation and review of adherence and potential interactions, and oversight of 

patient self-management of medications for diabetes, anti-coagulation management or warfarin 

therapy, and other chronic conditions, should be a routine part of all patient assessments. 

Markers of success include completion of the Annual Wellness Visit and documentation of 

 

2

 The Affordable Care Act (ACA) covered an annual wellness visit for Medicare beneficiaries through which they 

are to receive a personalized prevention plan. The ACA also ensured preventive services would be covered without 

cost if they are recommended by the US Preventive Services Taskforce and meet certain other conditions. 
CMS-1590-P 204 

medication reconciliation. 

4. Patient and Caregiver Engagement 

Truly patient-centered care assumes the mantra “nothing about me without me.” 

Providers should establish systems of care that include the patient in goal setting and decision 

making, creating opportunities for patient engagement throughout the care delivery process. 

Markers of success include policies and procedures designed to ensure that patient preferences 

are sought and incorporated into treatment decisions. 

5. Coordination of Care across the Medical Neighborhood 

The “medical neighborhood” is the totality of providers, related non-health services and 

patients in an area, and the ways in which they work together.3

 Primary care can be seen as the 

hub of the neighborhood and must take the lead in coordinating care. In particular, primary care 

providers must move towards leadership of health teams both within and outside their practice’s 

walls. Providers must have the ability to access a single medical record shared by the whole 

team; the content of this record can be leveraged to manage communication and information 

flow in support of referrals to other clinicians, and to support safe and effective transitions from 

the hospital and skilled nursing facilities back to the community. The primary care practice must 

also include personnel who are qualified to assist patients to manage post transition changes in 

conditions and treatments required to support patients’ health and reduce their need for 

readmission. Markers of success include the presence of standard processes and documents for 

communicating key information during care transitions or upon referral to other providers. 

b. Advanced Primary Care Practices Accreditation and Infrastructure 

1. Accreditation Utilizing Nationally Recognized Organizations 

 In the event that we were to establish an enhanced payment for primary care services 

 

3

 “Coordinating Care in the Medical Neighborhood” White Paper. Agency for Healthcare Research and Quality, 

June 2011. 
CMS-1590-P 205 

furnished to Medicare beneficiaries in an advanced primary care practice environment, we would 

need to establish a set of parameters to determine whether or not a clinical practice could be 

considered an advanced primary care practice (medical home). The foundation for our 

assessment could be whether the practice has the capacity to deliver comprehensive primary care 

services that mirror the five functions of the CPC initiative. However, we would need to identify 

explicit criteria in the form of documented processes and quantifiable practice attributes, such as 

the availability and capacity of electronic health records, to assess the presence of these five 

functions. 

 We could make our determination that a practice has implemented all identified functions 

and is, therefore, an advanced primary care practice, by recognizing one or more of the 

nationally available accreditation programs currently in use by major organizations that provide 

accreditation for advanced primary care practices, frequently credentialed as “PCMHs”. Having 

established recognition of accreditation by one of several national accreditation organizations, 

we might require that a provider document through the enrollment process (PECOS) that the 

practice meets the definition of an Advanced Primary Care Practice to furnish comprehensive 

primary care services. We have identified four national models that provide accreditation for 

organizations wishing to become an advanced primary care practice; the Accreditation 

Association for Ambulatory Health, The Joint Commission, the NCQA, and the Utilization 

Review Accreditation Commission (URAC). While there are similarities between all four of the 

national models for PCMH accreditation, each model has different standards and areas of 

emphasis in its review and approval of organizational capacity and function as a PCMH. For 

instance, according to a report prepared for CMS by the Urban Institute entitled, “PatientCentered Medical Home Recognition Tools: A Comparison of Ten Surveys’ Content and 

Operational Details” released in March of 2012, the NCQA places a heavier emphasis on Health 
CMS-1590-P 206 

IT than the other accrediting bodies in their measurement standards. This report can be viewed 

at the following link: http://www.urban.org/uploadedpdf/412338-patient-centered-medicalhome-rec-tools.pdf. 

 We believe that basing our determination on accreditation as a PCMH by a national 

accreditation organization would offer a number of benefits, including that their accreditation 

tools, which review specific aspects of practice including information systems and organizational 

processes already are well known, widely used, and well respected. Level 3 NCQA 

accreditation, URAC, the Accreditation Association for Ambulatory Health and Joint 

Commission accreditation standards are, despite their differences, very similar to the concepts of 

the comprehensive primary care services, and CMS could consider accepting accreditation from 

any of these as documentation that a group practice is an advanced primary care practice. Other 

payers currently recognize PCMH accreditation by these organizations for payment. A 

publication from the Medical Group Management Association (MGMA) “The Patient Centered 

Medical Home Guidelines: A Tool to Compare National Programs” found that all four of the 

national accreditation programs met the guidelines set forth by the AAFP, the AAP, the ACP, 

and AOA in their 2011 guidelines. The MGMA report can be downloaded from the following 

Website: http://www.mgma.com/Books/Patient-Centered-Medical-Home-Guidelines/. 

However, we recognize that the cost to a practice to acquire accreditation from one of these 

accrediting organizations could be significant. In addition, the processes to receive accreditation 

as an advanced primary care practice under these guidelines can be lengthy. We also are 

concerned that some parts of the accreditation processes for these accrediting organizations 

would be considered proprietary. We believe that Medicare payment should rely whenever 

feasible on criteria and tools that are in the public domain. We also recognize that it could be 

challenging for us to address how we could rely on a set of standards from a private accrediting 
CMS-1590-P 207 

body while still retaining responsibility for accreditation outcomes. It is unclear at this time how 

we would balance the proprietary interests of these private organizations in their accreditation 

models with our responsibility to establish and maintain appropriate transparency in our 

decision-making processes. 

 If we were to move forward with a process that would use the accreditation standards 

from a private sector organization to make determinations as to whether a practice is an 

advanced primary care practice, we would need to determine whether to recognize one, some, or 

all of the available and established accreditation models. As we stated above, because each 

accreditation tool has different standards and emphasizes different criteria, we are concerned that 

there could be consistency issues if we were to recognize accreditation from all four 

organizations as evidence of certification to provide advanced primary care. It would be 

important to ensure that any of the accreditation tool(s) we selected met the goals of our policy. 

We specifically invite comments regarding the processes that we should consider for application, 

confirmation that recognized accreditation standards are met, and notification of recognition as a 

PCMH if we were to recognize practices as advanced primary care practices based on 

accreditation as a PCMH by one or more of the national accreditation organizations. 

2. CMS-Developed Advanced Primary Care Accreditation Criteria 

 Alternatively, we could develop our own criteria using, for example, the five functions of 

comprehensive primary care used in the CPC initiative and described above, to determine what 

constitutes advanced primary care for purposes of Medicare payment. We would then need to 

develop a process for determining whether specific physician practices meet the criteria for 

advanced primary care. This could include creating our own criteria and processes for review or 

could include using existing accrediting bodies to measure compliance against advanced primary 

care criteria determined by CMS. This would create more consistent standards for identifying 
CMS-1590-P 208 

advanced primary care practices and provide greater transparency in the certification process. If 

CMS was able to determine the validity of an organization’s application to be recognized to be 

an advanced primary care practice, this could reduce the cost to the physician practice for 

accreditation. However, practices would still need to invest in organizational process and 

infrastructure to meet advanced primary care criteria. Implementing an internal process to 

accredit practices as advanced primary care for purposes of Medicare payment could involve 

significant administrative cost. The amount of cost likely would depend on the rigor of the 

required criteria, and the amount of documentation and review required prior to approval as an 

advanced primary care practice. 

 If we established our own criteria in order to resolve the lack of standardization between 

the standards adopted by the various national accreditation organizations for PCMH, it is 

possible that the accrediting bodies would then be able to assist us in determining compliance 

with the CMS criteria. Depending on the nature of the criteria, the CMS criteria may cost less to 

implement but would likely require a practice to incur the cost for an accrediting body to review 

the practice’s compliance. We invite public comment on the potential approaches we could use 

to identify advanced primary care practices for purposes of Medicare payment, including the 

possible use of one or more national accrediting organizations (and whether meaningful use of 

certified electronic health record technology should be required for such accreditation)as part of 

a Medicare approval process, as well as any other potential approaches to accrediting advanced 

primary care practices that we have not discussed here. 

c. Beneficiary Attribution for Purposes of Payment 

 One potential issue surrounding comprehensive primary care services delivered in an 

advanced primary care practice is attribution of a beneficiary to an advanced primary care 

practice. We would not expect that there would be more than one practice functioning as an 
CMS-1590-P 209 

advanced primary care practice for a beneficiary at any given time. However, in a fee-forservice environment we would need to determine which practice is currently serving as the 

advanced primary care practice for the beneficiary in order to ensure appropriate payment. One 

method of attribution could be that each beneficiary prospectively chooses an advanced primary 

care practice. We seek comment on how such a choice might be documented and incorporated 

into the fee-for-service environment. Other attribution methodologies might examine the 

quantity and type of E/M or other designated services furnished to that beneficiary by the 

practice. We welcome input on the most appropriate approach to the issue of how to best 

determine the practice that is functioning as the advanced primary care practice for each 

beneficiary. We are not considering proposals that would restrict a beneficiary’s free choice of 

practitioners. 

 In summary, we believe that targeting primary care management payments to advanced 

primary care practices would have many merits including ensuring a basic level of care 

coordination and care management. We recognize that the advanced primary care model has 

demonstrated efficacy in improving the value of health care in several contexts, and we are 

exploring whether we can achieve these outcomes for the Medicare population through several 

demonstration projects. Careful analysis of the outcomes of these demonstration projects will 

inform our understanding of how this model of care affects the Medicare population and of 

potential PFS payment mechanisms for these services. At the same time, we also believe that 

there are many policy and operational issues to be considered when nationally implementing 

such a program within the PFS. Therefore, we generally invite broad public comment on the 

accreditation and attribution issues discussed above and any other aspect, including payment, of 

integrating an advanced primary care model in to the PFS. 
CMS-1590-P 210 
CMS-1590-P 211 

I. Payment for Molecular Pathology Services

For CY 2012, the AMA CPT Editorial Panel began creating new CPT codes to replace 

the current codes used to bill for molecular pathology services. The new codes describe distinct 

molecular pathology tests and test methods. CPT divided these new molecular pathology codes 

into Tiers. Tier 1 codes describe common gene-specific and genomic procedures. Tier 2 codes 

capture reporting for less common tests and each Tier 2 code represents a group of tests that 

involve similar technical resources and interpretive work. For CY 2012, CPT created 101 new 

molecular pathology codes; 92 new Tier 1 codes for individual tests and nine Tier 2 codes for 

common groups of tests. These codes appear in Table 21. We anticipate that CPT will create 

additional molecular pathology codes for CY 2013. 

We stated in our notice for the Clinical Laboratory Fee Schedule (CLFS) Annual Public 

Meeting (to be held July 16-17, 2012 at CMS headquarters in Baltimore, Maryland, more 

information at https://www.cms.gov//Medicare-Fee-for-ServicePayment/ClinicalLabFeeSched/Public_Meetings.html) that we are following our process to 

determine the appropriate basis and payment amounts for new clinical diagnostic laboratory 

tests, including the molecular pathology tests, under the CLFS for CY 2013. However, we also 

stated that we understand stakeholders in the molecular pathology community continue to debate 

whether Medicare should pay for molecular pathology tests under the CLFS or the PFS. 

Medicare pays for clinical diagnostic laboratory tests through the CLFS and for services that 

ordinarily require physician work through the PFS. We stated that we believe we would benefit 

from additional public comments on whether these tests are clinical diagnostic laboratory tests 

that should be paid under the CLFS or whether they are physicians’ services that should be paid 

under the PFS. Therefore, we said that we intend to solicit comment on this issue in this 

proposed rule, as well as public comment on pricing policies for these tests under the CLFS at 
CMS-1590-P 212 

the Annual Public Meeting. This section first discusses and requests comment on whether these 

molecular pathology CPT codes describe services that ordinarily require physician work, and 

then discusses our proposal to address payment for these CPT codes on the PFS, pending public 

comment on the first question. This proposal is parallel to the invitation to discuss at the CLFS 

Annual Public Meeting, the appropriate basis for establishing a payment amount for the 

molecular pathology CPT codes as clinical diagnostic laboratory tests under the CLFS. 

As detailed in section II.B.1. of this proposed rule, Medicare establishes payment under 

the PFS by setting RVUs for physician work, practice expense (PE), and malpractice expense for 

services that ordinarily require physician work. To establish RVUs for physician work, we 

conduct a clinical review of the relative physician work (time by intensity) required for each PFS 

service. This clinical review includes the review of RVUs recommended by the American 

Medical Association Relative Value Scale Update Committee (AMA RUC) and others. The 

AMA RUC-recommended physician work RVUs typically are based in part on results of a 

survey conducted by the relevant specialty society for a service. CMS establishes RVUs for PE 

under a resource-based PE methodology that considers the cost of direct inputs, as well as 

indirect PE costs. The AMA RUC, through the Practice Expense Subcommittee, recommends 

direct PE inputs to CMS, and the relevant specialty societies provide pricing information for 

those direct inputs to CMS. After we determine the appropriate direct PE inputs, the PE 

methodology is used to develop proposed PE RVUs. Physician work and PE RVUs for each 

CPT code are constructed to reflect the typical case; that is, they reflect the service as it is 

furnished in greater than 50 percent of Medicare cases. CMS establishes resource-based 

malpractice expense RVUs using weighted specialty-specific malpractice insurance premium 

data collected from commercial and physician-owned insurers in CY 2010 (74 FR 61758). For 

most services paid under the PFS, beneficiary cost-sharing is 20 percent of the payment amount. 
CMS-1590-P 213 

CMS establishes a payment rate for new clinical diagnostic laboratory tests under the 

CLFS by either crosswalking or gap-filling. Crosswalking is used when a new test code is 

comparable to an existing test code, multiple existing test codes, or a portion of an existing test 

code on the CLFS. Under this methodology, the new test code is assigned the local fee schedule 

amounts and the national limitation amount (NLA) of the existing test, with payment made at the 

lesser of the local fee schedule amount or the NLA. Gap-filling is used when no comparable test 

exists on the CLFS. In the first year, carrier-specific amounts are established for the new test 

code using the following sources of information: charges for the test and routine discounts to 

charges; resources required to perform the test; payment amounts determined by other payers; 

and charges, payment amounts, and resources required for other tests that may be comparable or 

otherwise relevant. For the second year, the NLA is calculated, which is the median of the 

carrier-specific amounts. See §414.508. Services paid under the CLFS do not include any 

physician work, although tests paid under the CLFS can involve interpretation by a laboratory 

technician, a chemist, or a geneticist – none of which are occupations that meet the statutory 

definition of a physician. While payments can vary geographically due to contractor discretion 

across locality areas (which are the same localities used for the GPCIs under the PFS), payments 

cannot exceed a NLA nor can they be adjusted once rates are determined. In the CY 2008 PFS 

final rule with comment period, we adopted a prospective reconsideration process for new tests 

paid under the CLFS, allowing a single year for Medicare and stakeholders to review pricing for 

new tests after the payment is initially established (72 FR 66275 through 66279, 66401 through 

66402). Finally, the statute waives beneficiary cost-sharing for clinical laboratory diagnostic 

tests paid on the CLFS. 

 For a handful of clinical laboratory services paid under the CLFS, we allow an additional 

payment under the PFS for the professional services of a pathologist when they meet the 
CMS-1590-P 214 

requirements for clinical consultation service as defined in §415.130. The PFS pays for services 

that ordinarily require the work of a physician and, with regard to pathology services, explicitly 

pays for both the professional and technical component of the services of a pathologist as defined 

in §415.130 including surgical pathology, cytopathology, hematology, certain blood banking 

services, clinical consultations, and interpretive clinical laboratory services. 

Molecular pathology tests are currently billed using combinations of longstanding CPT 

codes that describe each of the various steps required to perform a given test. This billing 

method is called “stacking” because different “stacks” of codes are billed depending on the 

components of the furnished test. Currently, all of the stacking codes are paid through the CLFS. 

One stacking code, CPT code 83912 (molecular diagnostics; interpretation and report) is paid on 

both the CLFS and the PFS. Payment for the interpretation and report of a molecular pathology 

test when furnished and billed by a physician is made under the PFS using the professional 

component (PC, or 26) of CPT code 83912 (83912-26). Payment for the interpretation and 

report of a molecular pathology test when furnished by non-physician laboratory staff is made 

under the CLFS using CPT code 83912. 

Since the creation of new molecular pathology CPT codes, there has been significant 

debate in the stakeholder community regarding whether these new molecular pathology codes 

describe physicians’ services that ordinarily require physician work and would be paid under the 

PFS, or whether they describe clinical diagnostic laboratory tests that would be paid on the 

CLFS. The AMA RUC reviewed the 101 new molecular pathology CPT codes and concluded 

that 79 of 101 new molecular pathology codes include work furnished by a physician. The 

American Clinical Laboratory Association (ACLA) has indicated that 32 of the 101 new 

molecular pathology codes are interpreted by a physician and that a physician may perform the 

technical component associated with of 2 of the 101 CPT codes. Only 15 of the 101 new codes 
CMS-1590-P 215 

appear on both the AMA RUC and ACLA list of codes that each believe include work furnished 

by a physician. Additionally, some stakeholders have suggested that all molecular pathology 

tests require physician interpretation and report. Other stakeholders have suggested that the 

interpretation and report of a molecular pathology test is not ordinarily required because the 

majority of the molecular pathology tests are clearly negative so interpretation and reporting 

generally are not necessary. In addition, some stakeholders have argued that molecular 

pathology tests are becoming more and more automated, and therefore generally do not require 

interpretation by a physician. 

In the CY 2012 PFS final rule (76 FR 73190), we stated that for CY 2012, Medicare 

would continue to use the existing stacking codes for the reporting and payment of these 

molecular pathology services, and that the 101 new CPT codes would not be valid for payment 

for CY 2012. We did this because we were concerned that we did not have sufficient 

information to know whether these new molecular pathology CPT codes describe clinical 

diagnostic laboratory tests or services that ordinarily require physician work. For CY 2013, we 

continue to have many of the same concerns that led us not to recognize the 101 molecular 

pathology CPT codes for payment for CY 2012. Specifically, we acknowledge that we are 

lacking definitive answers to the following questions: 

● Do each of the 101 molecular pathology CPT codes describe services that are 

ordinarily furnished by a physician? 

● Do each of these molecular pathology CPT codes ordinarily require interpretation and 

report? 

● What is the nature of that interpretation and does it typically require physician work? 

● Who furnishes interpretation services and how frequently? 

We are seeking public comment on these questions and the broader issue of whether the 
CMS-1590-P 216 

new molecular pathology codes describe physicians’ services that should be paid under the PFS, 

or if they describe clinical diagnostic laboratory tests that should be paid under the CLFS. 

As we continue to consider public comment on whether these molecular pathology CPT 

codes describe services that ordinarily require physician work, we want to ensure that there is a 

payment mechanism in place to pay for these CPT codes for CY 2013. We propose to price all 

of the 101 new molecular pathology codes through a single fee schedule, either the CLFS or the 

PFS. After meeting with stakeholders and reviewing each CPT code, we believe that there is 

little variation in the laboratory methodologies, as all of them employ gene sequencing 

processes. However, there are very different processes for establishing payment rates under the 

PFS and the CLFS. As discussed above, Medicare sets payment under the CLFS by either 

crosswalking or gap-filling and, after the prospective reconsideration process, currently cannot 

adjust the payment amount further. In contrast, Medicare sets payment under the PFS through a 

set of resource-based methodologies for physician work, PE, and malpractice expense, and 

payment can be reviewed and adjusted as the resources required to furnish a service change. We 

are concerned that establishing different prices for comparable laboratory services across two 

different payment systems would create a financial incentive to choose one test over another 

simply because of its fee schedule placement. We are also concerned that the differences in 

prices would become more pronounced over time as the PFS continues to review the values for 

physician work and PE inputs relative to established CLFS prices. Therefore, because of the 

homogeneity of the laboratory methodologies behind these procedure test codes, we believe that 

it is appropriate for all 101 new molecular pathology CPT codes to be priced on the same fee 

schedule using the same methodology. We invite public comment on this proposal. 

In our effort to determine the appropriate Medicare payment for these new molecular 

pathology codes, stakeholders will have the opportunity to discuss the CLFS payment basis for 
CMS-1590-P 217 

establishing payment amounts for the molecular pathology codes discussed above at the CLFS 

Annual Public Meeting in July 2012. Section 1833(h)(8)(A) of the Act, which discusses the 

CLFS, requires the Secretary to “establish by regulation procedures for determining the basis for, 

and amount of, payment [under the CLFS] for any clinical diagnostic laboratory test with respect 

to which a new or substantially revised HCPCS code is assigned on or after January 1, 2005.” 

Clauses (i) and (ii) of section 1833(h)(8)(B) of the Act requires the Secretary to: 1) make 

“available to the public (through an Internet website and other appropriate mechanisms) a list 

that includes any such test for which establishment of a payment amount... is being considered 

for a year;” and, “on the same day such list is made available, causes to have published in the 

Federal Register notice of a meeting to receive comments and recommendations (and data on 

which recommendations are based) from the public on the appropriate basis... for establishing 

payment amounts for the tests on such list.” Because we believe that these molecular pathology 

codes may be clinical diagnostic laboratory tests payable on the CLFS, comments and 

recommendations from the public on the appropriate basis for establishing payment amounts on 

the CLFS will be discussed at the CY 2013 CLFS Annual Public Meeting. More information on 

the CLFS Annual Public Meeting is available in the Federal Register at 77 FR 31620 through 

31622 and on the CMS Website at http://www.cms.hhs.gov/ClinicalLabFeeSched. 

As a parallel to our invitation to discuss these molecular pathology codes as clinical 

diagnostic laboratory tests at the CLFS Annual Public Meeting in July 2012, we also propose 

payment amounts for these codes under the PFS for CY 2013. The AMA RUC provided CMS 

with recommendations for physician work RVUs and PE inputs for the 79 CPT codes it believes 

include physician work. At our request, CAP provided CMS with direct PE input 

recommendations for 15 of the remaining 22 CPT codes to the best of their ability. We do not 

have recommendations on physician work RVUs or direct PE inputs for 7 of 101 codes which 
CMS-1590-P 218 

represent tests that are patented, and therefore the methodology used to furnish the service is 

proprietary and has been unavailable to the AMA RUC or CMS to support developing 

appropriate direct PE inputs. For the 79 CPT codes, the AMA RUC-recommended physician 

work RVUs range from 0.13 to 2.35, with a median work RVU of 0.45. The AMA RUCrecommended physician intra-service times (which, for these codes, equals the total times) range 

from 7 minutes to 80 minutes, with a median intra-service time of 18 minutes. We would note 

that the physician work RVU for CPT code 83912-26 and all but one of the other clinical 

diagnostic laboratory services for which CMS recognizes payment for clinical interpretation is 

0.37. Table 21 lists AMA RUC-recommended physician work RVUs and times for these 

services. 

Molecular pathology tests can be furnished in laboratories of different types and sizes 

(for example a large commercial laboratory or a pathologist’s office), and tests may be furnished 

in small or large batches. The methodologies used and resources involved in furnishing a 

specific test can vary from laboratory to laboratory. When developing direct PE input 

recommendations for CMS, CAP and the AMA RUC made assumptions about the typical 

laboratory setting and batch size to determine the typical direct PE inputs for each service. 

Given that many of these services are furnished by private laboratories, providing 

recommendations on the typical inputs was challenging for many services, and not possible for 

other services. The AMA RUC and CAP-recommended direct PE inputs are available on the 

CMS Website in the files supporting this CY 2013 PFS proposed rule at 

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFSFederal-Regulation-Notices.html. We appreciate all of the effort CAP has made to develop 

national pricing inputs. However, we agree with its view that, in many cases, there is no 

established protocol for executing many of these tests and that the potential means to execute 
CMS-1590-P 219 

these tests can vary considerably. 

In addition to recommendations on physician work and direct PE inputs, the AMA RUC 

provided CMS with recommended utilization crosswalks for the 79 molecular pathology services 

it believes are typically furnished by a physician. When there are coding changes, the utilization 

crosswalk tracks Medicare utilization from an existing code to a new code. The existing code 

utilization figures are drawn from Medicare claims data. We use utilization crosswalk 

assumptions to ensure PFS BN and to create PE RVUs through the PE methodology. Currently, 

payment for the interpretation and report of a molecular pathology test when furnished and billed 

by a physician is made under the PFS using CPT code 83912-26. Because CPT created the new 

molecular pathology codes to replace the current stacking codes, when recommending utilization 

crosswalks, the AMA RUC started with the total utilization for CPT code 83912-26, and divided 

that utilization among the 79 CPT codes. CAP has indicated that it distributed the utilization 

based, in part, on ICD-9 diagnosis data. Table 22 lists the AMA RUC-recommended utilization 

crosswalks for these services. 

We are concerned that the RUC-recommended utilization is too low because it is based 

on the utilization of CPT code 83912-26 only. Instead, we believe that the utilization 

assumptions for the technical component of the 101 new CPT codes should be based on the 

utilization of the corresponding CPT codes currently billed on the CLFS. Several laboratories 

provided us with a list of the molecular pathology tests that they perform, and identified the 

stacking codes that are currently used to bill for each test and the new CPT code that would be 

billed for each test. However, because the same molecular pathology test may be billed using 

different stacks, and the same stack may be billed for different tests, it is not possible to 

determine which stacks match which new CPT codes for all Medicare claims. Additionally, if a 

beneficiary has more than one test on the same date of service and both stacks are billed on the 
CMS-1590-P 220 

same Medicare claim, it is not possible to determine which stacking codes on the claim make up 

each stack. Furthermore, some tests described by the new CPT codes are currently billed using 

general “not otherwise classified” (NOC) pathology CPT codes that capture a range of services 

and not just the molecular pathology tests described by the new CPT codes. Given these factors, 

it is difficult to estimate the utilization of the 101 new molecular pathology codes based on the 

Medicare billing of the current stacking and NOC codes. 

If we were to finalize payment for molecular pathology services under the PFS, we do not 

believe that we could propose national payment rates at this time. Many outstanding questions 

remain including: 

● If these services are furnished by a physician, what are the appropriate physician work 

RVUs and times relative to other similar services? 

● Where and how are each of these services typically furnished—for example, what is 

the typical laboratory setting and batch size? 

● What is the correct projected utilization for each of these services? 

Given these major areas of uncertainty, if CMS determined that new molecular pathology 

CPT codes should be paid under the PFS for CY 2013, we are proposing to allow the Medicare 

contractors to price these codes because we do not believe we have sufficient information to 

engage in accurate national pricing and because the price of tests can vary locally. As previously 

discussed, this proposal is a parallel to the invitation to discuss at the CLFS Annual Public 

Meeting the appropriate basis for establishing a payment amount for these molecular pathology 

tests as clinical diagnostic laboratory tests under the CLFS. If we decide to finalize payment for 

these new codes under the PFS, we would consider modifying §415.130 as appropriate to 

provide for payment to a pathologist for molecular pathology services. 
CMS-1590-P 221 

After reviewing comments received on the proposals contained within this CY 2013 PFS 

proposed rule, and after hearing the discussion at the CLFS Annual Public Meeting, we will 

determine the appropriate basis for establishing payment amounts for the new molecular 

pathology codes. We intend to publish our final decision in the CY 2013 PFS final rule with 

comment period and, at the same time that rule is published, as stated in the CLFS Public 

Meeting Notice, to post final payment determinations, if any, for the molecular pathology tests 

that will be paid under the CLFS. 

TABLE 21: AMA RUC-Recommended Physician Work RVUs and Times for New 

Molecular Pathology CPT Codes 

CPT Code Short Descriptor 

AMA RUCRecommended Physician 

Work RVU 

AMA RUCRecommended Physician 

Intra-service Time 

(Minutes) 

81206 Bcr/abl1 gene major bp 0.37 15 

81207 Bcr/abl1 gene minor bp 0.15 11 

81208 Bcr/abl1 gene other bp 0.46 18 

81210 Braf gene 0.37 15 

81220 Cftr gene com variants 0.15 10 

81221 Cftr gene known fam variants 0.40 20 

81222 Cftr gene dup/delet variants 0.22 13 

81223 Cftr gene full sequence 0.40 20 

81224 Cftr gene intron poly t 0.15 10 

81225 Cyp2c19 gene com variants 0.37 13 

81226 Cyp2d6 gene com variants 0.43 15 

81227 Cyp2c9 gene com variants 0.38 14 

81240 F2 gene 0.13 7 

81241 F5 gene 0.13 8 

81243 Fmr1 gene detection 0.37 15 

81244 Fmr1 gene characterization 0.51 20 

81245 Flt3 gene 0.37 15 

81256 Hfe gene 0.13 7 

81257 Hba1/hba2 gene 0.50 20 

81261 Igh gene rearrange amp meth 0.52 21 

81262 Igh gene rearrang dir probe 0.61 20 

81263 Igh vari regional mutation 0.52 23 

81264 Igk rearrangeabn clonal pop 0.58 22 

81265 Str markers specimen anal 0.40 17 

81266 Str markers spec anal addl 0.41 15 

81267 Chimerism anal no cell selec 0.45 18 

81268 Chimerism anal w/cell select 0.51 20 

81270 Jak2 gene 0.15 10 

81275 Kras gene 0.50 20 

81291 Mthfr gene 0.15 10 

81292 Mlh1 gene full seq 1.40 60 

81293 Mlh1 gene known variants 0.52 28 
CMS-1590-P 222 

CPT Code Short Descriptor 

AMA RUCRecommended Physician 

Work RVU 

AMA RUCRecommended Physician 

Intra-service Time 

(Minutes) 

81294 Mlh1 gene dup/delete variant 0.80 30 

81295 Msh2 gene full seq 1.40 60 

81296 Msh2 gene known variants 0.52 28 

81297 Msh2 gene dup/delete variant 0.80 30 

81298 Msh6 gene full seq 0.80 30 

81299 Msh6 gene known variants 0.52 28 

81300 Msh6 gene dup/delete variant 0.65 30 

81301 Microsatellite instability 0.50 20 

81302 Mecp2 gene full seq 0.65 30 

81303 Mecp2 gene known variant 0.52 28 

81304 Mecp2 gene dup/delet variant 0.52 28 

81310 Npm1 gene 0.39 19 

81315 Pml/raralpha com breakpoints 0.37 15 

81316 Pml/raralpha 1 breakpoint 0.22 12 

81317 Pms2 gene full seq analysis 1.40 60 

81318 Pms2 known familial variants 0.52 28 

81319 Pms2 gene dup/delet variants 0.80 30 

81331 Snrpn/ube3a gene 0.39 15 

81332 Serpina1 gene 0.40 15 

81340 Trb@ gene rearrange amplify 0.63 25 

81341 Trb@ gene rearrange dirprobe 0.45 19 

81342 Trg gene rearrangement anal 0.57 25 

81350 Ugt1a1 gene 0.37 15 

81355 Vkorc1 gene 0.38 15 

81370 Hla i & ii typing lr 0.54 15 

81371 Hla i & ii type verify lr 0.60 30 

81372 Hla i typing complete lr 0.52 15 

81373 Hla i typing 1 locus lr 0.37 15 

81374 Hla i typing 1 antigen lr 0.34 13 

81375 Hla ii typing ag equiv lr 0.60 15 

81376 Hla ii typing 1 locus lr 0.50 15 

81377 Hla ii type 1 ag equiv lr 0.43 15 

81378 Hla i & ii typing hr 0.45 20 

81379 Hla i typing complete hr 0.45 15 

81380 Hla i typing 1 locus hr 0.45 15 

81381 Hla i typing 1 allele hr 0.45 12 

81382 Hla ii typing 1 loc hr 0.45 15 

81383 Hla ii typing 1 allele hr 0.45 15 

81400 Mopath procedure level 1 0.32 10 

81401 Mopath procedure level 2 0.40 15 

81402 Mopath procedure level 3 0.50 20 

81403 Mopath procedure level 4 0.52 28 

81404 Mopath procedure level 5 0.65 30 

81405 Mopath procedure level 6 0.80 30 

81406 Mopath procedure level 7 1.40 60 

81407 Mopath procedure level 8 1.85 60 

81408 Mopath procedure level 9 2.35 80 
CMS-1590-P 223 

TABLE 22: AMA RUC-Recommended Utilization Crosswalks for New Molecular 

Pathology CPT Codes

Source Destination Analytic Ratio* 

83912 26 81206 0.116 

83912 26 81207 0.003 

83912 26 81208 0.003 

83912 26 81210 0.020 

83912 26 81220 0.017 

83912 26 81221 0.003 

83912 26 81222 0.003 

83912 26 81223 0.003 

83912 26 81224 0.003 

83912 26 81225 0.006 

83912 26 81226 0.006 

83912 26 81227 0.011 

83912 26 81240 0.073 

83912 26 81241 0.110 

83912 26 81243 0.003 

83912 26 81244 0.000 

83912 26 81245 0.014 

83912 26 81256 0.050 

83912 26 81257 0.014 

83912 26 81261 0.014 

83912 26 81262 0.002 

83912 26 81263 0.001 

83912 26 81264 0.011 

83912 26 81265 0.043 

83912 26 81266 0.001 

83912 26 81267 0.006 

83912 26 81268 0.001 

83912 26 81270 0.050 

83912 26 81275 0.050 

83912 26 81291 0.017 

83912 26 81292 0.003 

83912 26 81293 0.001 

83912 26 81294 0.002 

83912 26 81295 0.003 

83912 26 81296 0.001 

83912 26 81297 0.002 

83912 26 81298 0.001 

83912 26 81299 0.002 

83912 26 81300 0.001 

83912 26 81301 0.003 

83912 26 81302 0.001 

83912 26 81303 0.000 

83912 26 81304 0.000 

83912 26 81310 0.014 

83912 26 81315 0.017 

83912 26 81316 0.003 

83912 26 81317 0.002 

83912 26 81318 0.001 

83912 26 81319 0.001 

83912 26 81331 0.001 

83912 26 81332 0.003 

83912 26 81340 0.011 

83912 26 81341 0.003 

83912 26 81342 0.017 

83912 26 81350 0.002 

83912 26 81355 0.011 

83912 26 81370 0.043 

83912 26 81371 0.029 

83912 26 81372 0.011 

83912 26 81373 0.011 

83912 26 81374 0.029 

83912 26 81375 0.006 

83912 26 81376 0.006 

83912 26 81377 0.006 

83912 26 81378 0.006 

83912 26 81379 0.003 

83912 26 81380 0.003 

83912 26 81381 0.003 

83912 26 81382 0.003 

83912 26 81383 0.003 

83912 26 81400 0.007 

83912 26 81401 0.007 

83912 26 81402 0.007 

83912 26 81403 0.007 

83912 26 81404 0.007 

83912 26 81405 0.007 

83912 26 81406 0.003 

83912 26 81407 0.003 

83912 26 81408 0.003 

*Percentage of source code utilization transferred to 

the destination code 
CMS-1590-P 224 

J. Payment for New Preventive Service HCPCS G-Codes

Under section 1861(ddd) of the Act, as amended by Section 4105 of the Affordable Care 

Act, CMS is authorized to add coverage of “additional preventive services” if certain statutory 

criteria are met as determined through the national coverage determination (NCD) process, 

including that the service meets all of the following criteria: (1) they must be reasonable and 

necessary for the prevention or early detection of illness or disability, (2) they must be 

recommended with a grade of A or B by the United States Preventive Services Task Force 

(USPSTF), and (3) they must be appropriate for individuals entitled to benefits under Part A or 

enrolled under Part B. After reviewing the USPSTF recommendations for the preventive 

services, conducting evidence reviews, and considering public comments under the NCD 

process, we determined that the above criteria were met for the services listed in Table 23. 

Medicare now covers each of the following preventive services: 

● Screening and Behavioral Counseling Interventions in Primary Care to Reduce 

Alcohol Misuse, effective October 14, 2011; 

● Screening for Depression in Adults, effective October 14, 2011; 

● Screening for Sexually Transmitted Infections (STIs) and High Intensity Behavioral 

Counseling (HIBC) to Prevent STIs, effective November 8, 2011; 

● Intensive Behavioral Therapy for Cardiovascular Disease, effective November 8, 

2011; and 

● Intensive Behavioral Therapy for Obesity, effective November 29, 2011. 

Table 23 lists the HCPCS G-codes created for reporting and payment of these services. 

The Medicare PFS payment rates for these services are discussed below. The NCD process 

establishing coverage of these preventive services was not complete at the time of publication of 

the CY 2012 PFS final rule in early November, so we could not indicate interim RVUs for these 
CMS-1590-P 225 

preventive services in our final rule addenda. However, we were able to include HCPCS Gcodes and national payment amounts for these services in the CY 2012 PFS national relative 

value files, which became available at the end of the year and were effective January 1, 2012. 

From the effective date of each service to December 31, 2011, the payment amount for these 

codes was established by the Medicare Administrative Contractors. 

TABLE 23: New Preventive Service HCPCS G-Codes 

HCPCS 

Code 

HCPCS Code Long Descriptor CMS National Coverage 

Determination (NCD) 

CMS Change 

Request (CR) 

G0442 Annual alcohol misuse screening, 15 

minutes 

Screening and Behavioral Counseling 

Interventions in Primary Care to 

Reduce Alcohol Misuse (NCD 210.8) 

CR7633 

G0443 Brief face-to-face behavioral counseling 

for alcohol misuse, 15 minutes 

Screening Behavioral Counseling 

Interventions in Primary Care to 

Reduce Alcohol Misuse (NCD 210.8) 

CR7633 

G0444 Annual Depression Screening, 15 minutes Screening for Depression in Adults 

(NCD 210.9) 

CR7637 

G0445 High-intensity behavioral counseling to 

prevent sexually transmitted infections, 

face-to-face, individual, includes: 

education, skills training, and guidance on 

how to change sexual behavior; 

performed semi-annually, 30 minutes 

Screening for Sexually Transmitted 

infections(STIs) and High- Intensity 

Behavioral Counseling (HIBC) to 

prevent STIs (NCD 210.10) 

CR7610 

G0446 Annual, face-to-face intensive behavioral 

therapy for cardiovascular disease, 

individual, 15 minutes 

Intensive Behavioral Therapy for 

Cardiovascular Disease (NCD 210.11) 

CR7636 

G0447 Face-to-face behavioral counseling for 

obesity, 15 minutes 

Intensive Behavioral Therapy for 

Obesity (NCD 210.12) 

CR7641 

Two new HCPCS codes, G0442 (Annual alcohol misuse screening, 15 minutes), and 

G0443 (Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes), were created 

for the reporting and payment of screening and behavioral counseling interventions in primary 

care to reduce alcohol misuse. 

We believe that the screening service described by HCPCS code G0442 requires similar 

physician work as CPT code 99211 (Level 1 office or other outpatient visit, established patient), 

that may not require the presence of a physician. CPT code 99211 has a work RVU of 0.18 and 

we believe HCPCS code G0442 should be valued similarly. As such, we are proposing a work 

RVU of 0.18 for HCPCS code G0442 for CY 2013. For physician time, we are proposing 15 
CMS-1590-P 226 

minutes, which is the amount of time specified in the HCPCS code descriptor. For malpractice 

expense, we are proposing a malpractice expense crosswalk to CPT code 99211. The proposed 

direct PE inputs are reflected in the CY 2013 proposed direct PE input database, available on the 

CMS Website under the downloads for the CY 2013 PFS proposed rule at 

http://www.cms.gov/PhysicianFeeSched/. We request public comment on these CY 2013 

proposed values for HCPCS code G0442, which are the same as the current (CY 2012) values 

for this service. 

We believe that the behavioral counseling service described by HCPCS code G0443 

requires similar physician work to CPT code 97803 (Medical nutrition therapy; re-assessment 

and intervention, individual, face-to-face with the patient, each 15 minutes) (work RVU = 0.45) 

and should be valued similarly. As such, we are proposing a work RVU of 0.45 for HCPCS 

code G0443 for CY 2013. For physician time, we are proposing 15 minutes, which is the 

amount of time specified in the HCPCS code descriptor. For malpractice expense, we are 

proposing a malpractice expense crosswalk to CPT code 97803. The proposed direct PE inputs 

are reflected in the CY 2013 proposed direct PE input database, available on the CMS Website 

under the downloads for the CY 2013 PFS proposed rule at 

http://www.cms.gov/PhysicianFeeSched/. We request public comment on these CY 2013 

proposed values for HCPCS code G0443, which are the same as the current (CY 2012) values 

for this service. 

HCPCS code G0444 (Annual Depression Screening, 15 minutes) was created for the 

reporting and payment of screening for depression in adults. 

We believe that the screening service described by HCPCS code G0444 requires similar 

physician work as CPT code 99211 (work RVU = 0.18) and should be valued similarly. As 

such, we are proposing a work RVU of 0.18 for HCPCS code G0444 for CY 2013. For 
CMS-1590-P 227 

physician time, we are proposing 15 minutes, which is the amount of time specified in the 

HCPCS code descriptor. For malpractice expense, we are proposing a malpractice expense 

crosswalk to CPT code 99211. The proposed direct PE inputs are reflected in the CY 2013 

proposed direct PE input database, available on the CMS Website under the downloads for the 

CY 2013 PFS proposed rule at http://www.cms.gov/PhysicianFeeSched/. We request public 

comment on these CY 2013 proposed values for HCPCS code G0444, which are the same as the 

current (CY 2012) values for this service. 

HCPCS code G0445 (high-intensity behavioral counseling to prevent sexually 

transmitted infections, face-to-face, individual, includes: education, skills training, and guidance 

on how to change sexual behavior, performed semi-annually, 30 minutes) was created for the 

reporting and payment of HIBC to prevent STIs. 

We believe that the behavioral counseling service described by HCPCS code G0445 

requires similar physician work to CPT code 97803 (work RVU = 0.45) and should be valued 

similarly. As such, we are proposing a work RVU of 0.45 for HCPCS code G0445 for CY 2013. 

For physician time, we are proposing 30 minutes, which is the amount of time specified in the 

HCPCS code descriptor. For malpractice expense, we are proposing a malpractice expense 

crosswalk to CPT code 97803. The proposed direct PE inputs are reflected in the CY 2013 

proposed direct PE input database, available on the CMS Website under the downloads for the 

CY 2013 PFS proposed rule at http://www.cms.gov/PhysicianFeeSched/. We request public 

comment on these CY 2013 proposed values for HCPCS code G0445, which are the same as the 

current (CY 2012) values for this service. 

HCPCS code G0446 (Annual, face-to-face intensive behavioral therapy for 

cardiovascular disease, individual, 15 minutes) was created for the reporting and payment of 

intensive behavioral therapy for cardiovascular disease. 
CMS-1590-P 228 

We believe that the behavioral therapy service described by HCPCS code G0446 requires 

similar physician work to CPT code 97803 (work RVU = 0.45) and should be valued similarly. 

As such, we are proposing a work RVU of 0.45 for HCPCS code G0446 for CY 2013. For 

physician time, we are proposing 15 minutes, which is the amount of time specified in the 

HCPCS code descriptor. For malpractice expense, we are proposing a malpractice expense 

crosswalk to CPT code 97803. The proposed direct PE inputs are reflected in the CY 2013 

proposed direct PE input database, available on the CMS Website under the downloads for the 

CY 2013 PFS proposed rule at http://www.cms.gov/PhysicianFeeSched/. We request public 

comment on these CY 2013 proposed values for HCPCS code G0446, which are the same as the 

current (CY 2012) values for this service. 

HCPCS G0447 (Face-to-face behavioral counseling for obesity, 15 minutes) was created 

for the reporting and payment of intensive behavioral therapy for obesity. 

We believe that the behavioral counseling service described by HCPCS code G0447 

requires similar physician work to CPT code 97803 (work RVU = 0.45) and should be valued 

similarly. As such, we are proposing a work RVU of 0.45 for HCPCS code G0447 for CY 2013. 

For physician time, we are proposing 15 minutes, which is the amount of time specified in the 

HCPCS code descriptor. For malpractice expense, we are proposing a malpractice expense 

crosswalk to CPT code 97803. The proposed direct PE inputs are reflected in the CY 2013 

proposed direct PE input database, available on the CMS Website under the downloads for the 

CY 2013 PFS proposed rule at http://www.cms.gov/PhysicianFeeSched/. We request public 

comment on these CY 2013 proposed values for HCPCS code G0447, which are the same as the 

current (CY 2012) values for this service. 

K. Certified Registered Nurse Anesthetists and Chronic Pain Management Services
CMS-1590-P 229 

The benefit category for services furnished by a certified registered nurse anesthetist 

(CRNA) was added to Medicare by section 9320 of the Omnibus Budget Reconciliation Act 

(OBRA) 1986. Since this benefit was implemented on January 1, 1989, CRNAs have been 

eligible to bill Medicare directly for the specified services. Section 1861(bb)(2) of the Act 

defines a CRNA as “a certified registered nurse anesthetist licensed by the State who meets such 

education, training, and other requirements relating to anesthesia services and related care as the 

Secretary may prescribe. In prescribing such requirements the Secretary may use the same 

requirements as those established by a national organization for the certification of nurse 

anesthetists.” 

 Section 410.69(b) defines a CRNA as a registered nurse who: (1) is licensed as a 

registered professional nurse by the State in which the nurse practices; (2) meets any licensure 

requirements the State imposes with respect to nonphysician anesthetists; (3) has graduated from 

a nurse anesthesia educational program that meets the standards of the Council on Accreditation 

of Nurse Anesthesia Programs, or such other accreditation organization as may be designated by 

the Secretary; and (4) meets one of the following criteria: (i) has passed a certification 

examination of the Council on Certification of Nurse Anesthetists, the Council on Recertification 

of Nurse Anesthetists, or any other certification organization that may be designated by the 

Secretary; or (ii) is a graduate of a program described in paragraph (3) of this definition and 

within 24 months after that graduation meets the requirements of paragraph (4)(i) of this 

definition. 

Section 1861(bb)(1) of the Act defines services of a CRNA as “anesthesia services and 

related care furnished by a certified registered nurse anesthetist (as defined in paragraph (2)) 

which the nurse anesthetist is legally authorized to perform as such by the State in which the 

services are furnished”. CRNAs are paid at the same rate as physicians for furnishing such 
CMS-1590-P 230 

services to Medicare beneficiaries. Payment for services furnished by CRNAs only differs from 

physicians in that payment to CRNAs is made only on an assignment-related basis (§414.60) and 

supervision requirements apply in certain circumstances. 

At the time that the Medicare benefit for CRNA services was established, CRNA practice 

largely occurred in the surgical setting and services other than anesthesia (medical and surgical) 

were furnished in the immediate pre- and post-surgery timeframe. The scope of “anesthesia 

services and related care” as delineated in section 1861(bb)(1) of the Act reflected that practice 

standard. As CRNAs have moved into other practice settings, questions have arisen regarding 

what services are encompassed under the “related care” aspect of the benefit category. 

Specifically, some CRNAs now offer chronic pain management services that are separate and 

distinct from a surgical procedure. Changes in CRNA practice have prompted questions as to 

whether these services fall within the scope of section 1861(bb)(1) of the Act. Medicare 

Administrative Contractors (MACs) have reached different conclusions as to whether the 

statutory description of “anesthesia services and related care” encompasses the chronic pain 

management services delivered by CRNAs. As a result, we have been asked to address whether 

or not chronic pain management is included within the scope of the statutory benefit for CRNA 

services. 

To determine whether chronic pain management is included in the statutory benefit for 

CRNA services, we reviewed our current regulations and subregulatory guidance. We found that 

the existing guidance does not specifically address chronic pain management. In the Internet 

Only Manual (Pub 100-04, Ch 12, Sec 140.4.3), we discuss the medical or surgical services that 

fall under the “related care” language stating, “These may include the insertion of Swan Ganz 

catheters, central venous pressure lines, pain management, emergency intubation, and the preanesthetic examination and evaluation of a patient who does not undergo surgery.” Some have 
CMS-1590-P 231 

interpreted the reference to “pain management” in this language as authorizing direct payment to 

CRNAs for chronic pain management services, while others have taken the view that the services 

highlighted in the manual language are services furnished in the perioperative setting and refer 

only to acute pain management associated with the surgical procedure. 

Since existing guidance was not determinative, we assessed the issue of CRNA practice 

of chronic pain management more broadly. We found that chronic pain management is an 

emerging field. The Institute of Medicine (IOM) issued a report entitled “Relieving Pain in 

America: A Blueprint for Transforming Prevention, Care, Education and Research” on June 29, 

2011, discussing the importance of pain management and focusing on the many challenges in 

delivering effective chronic pain management. The available interventions to treat chronic pain 

have been expanding. In addition to the use of medications and a variety of diagnostic tests, 

techniques include neural blocks, neuromodulatory techniques, and implanted pain management 

devices. The healthcare community continues to examine the appropriateness and effectiveness 

of these many and varied treatment techniques and modalities. As part of this evolution, 

Medicare established a physician specialty code for interventional pain management in 2003. 

The healthcare community continues to debate whether CRNAs are qualified to provide 

chronic pain management. Some have stated that interventional pain management for 

beneficiaries with chronic pain is the practice of medicine, that CRNAs do not receive the 

sufficient education on chronic pain management, and that CRNAs do not have the skills 

required to furnish chronic pain management services. Others have stated that both acute and 

chronic pain management and treatment are within the CRNA professional scope and are 

comparable services, and that CRNAs receive the clinical training and experience necessary to 

furnish both acute and chronic pain management services. Recently, several State legislatures 
CMS-1590-P 232 

have debated the scope of CRNA practice, including those in the States of California, Colorado, 

Missouri, South Carolina, Nevada, and Virginia. 

In the context of Medicare, some have pointed to Medicare policies allowing other 

advanced practice nurses such as nurse practitioners or clinical nurse specialists to furnish and 

bill for physicians’ services as support for recognizing a broader interpretation of the scope of 

CRNA practice. We would note that the statutory benefit category definition for CRNAs 

substantively differs from that for other advanced practice nurses. Section 1861(s)(2)(K) of the 

Act authorizes certain nonphysician practitioners (NPPs) to bill Medicare directly for services 

they are legally authorized to perform under State law, and “which would be physicians’ services 

if furnished by a physician.” With certain conditions (such as physician supervision or 

collaboration), the statute allows these NPPs to bill Medicare for physicians’ services that fall 

within their State scope of practice. 

Since State governments regulate the licensure and practice of specific types of health 

care professionals, we have looked to the State scope of practice laws to determine if chronic 

pain management was within the scope of practice for CRNAs. State scope of practice laws vary 

with regard to the range of services that CRNAs may perform, and some include chronic pain 

management. As discussed earlier, several States are debating whether to include chronic pain 

management services within the CRNA scope of practice. 

After assessing the information available to us, we have concluded that chronic pain 

management is an evolving field, and we recognize that certain States have determined that the 

scope of practice for a CRNA should include chronic pain management in order to meet health 

care needs of their residents and ensure their health and safety. Therefore, we propose to revise 

our regulations at §410.69(b) to define the statutory description of CRNA services. Specifically, 

we propose to add the following language: “Anesthesia and related care includes medical and 
CMS-1590-P 233 

surgical services that are related to anesthesia and that a CRNA is legally authorized to perform 

by the State in which the services are furnished.” This proposed definition would set a Medicare 

standard for the services that can be furnished and billed by CRNAs while allowing appropriate 

flexibility to meet the unique needs of each State. The proposal also dovetails with the language 

in section 1861(bb)(1) of the Act requiring the State’s legal authorization to perform CRNA 

services as a key component of the CRNA benefit category. Finally, the proposed definition is 

also consistent with our policy to recognize State scope of practice as one parameter defining the 

services that can be furnished and billed by other NPPs. 

Simply because the State allows a certain type of health care professional to furnish 

certain services does not mean that all members of that profession are adequately trained to 

provide the service. In the case of chronic pain management, the IOM report specifically noted 

that many practitioners lack the skills needed to help patients with the day-to-day selfmanagement that is required to properly serve individuals with chronic pain. As with all 

practitioners who furnish services to Medicare beneficiaries, CRNAs practicing in States that 

allow them to furnish chronic pain management services are responsible for obtaining the 

necessary training for any and all services furnished to Medicare beneficiaries. 

L. Ordering of Portable X-Ray Services 

Portable x-ray suppliers provide diagnostic imaging services at a patient’s location. 

These services are most often furnished in residences, including private homes and group living 

facilities (for example, nursing homes) rather than in a traditional clinical setting (for example, a 

doctor’s office or hospital). The supplier transports mobile diagnostic imaging equipment to the 

patient’s location, sets up the equipment, and administers the test onsite. The supplier may 

interpret the results itself or it may provide the results to an outside physician for interpretation. 
CMS-1590-P 234 

Portable x-ray services may avoid the need for expensive ambulance transport of frail patients to 

a radiology facility or hospital. 

In the Medicare Conditions for Coverage regulations established in 1969, §486.106(a), 

requires that “portable x-ray examinations are performed only on the order of a doctor of 

medicine (MD) or doctor of osteopathy (DO) licensed to practice in the State...” With the 

exception of portable x-ray services, Medicare payment regulations at §410.32 allow physicians, 

including limited-license practitioners such as doctors of podiatry and optometry, and most 

nonphysician practitioners who furnish physicians’ services to order diagnostic x-ray tests, 

diagnostic laboratory tests, and other diagnostic tests so long as those nonphysician practitioners 

are operating within the scope of their authority under State law and within the scope of their 

Medicare statutory benefit. 

Nonphysician practitioners have become an increasingly important component of clinical 

care, and we believe that delivery systems should take full advantage of all members of a 

healthcare team, including nonphysician practitioners.

Although current Medicare regulations limit ordering of portable x-ray services to a MD 

or a DO, the Office of the Inspector General (OIG) in its December 2011 report entitled 

“Questionable Billing Patterns of Portable X-Ray Suppliers” (OEI-12-10-00190) found that 

Medicare was paying for portable x-ray services ordered by physicians other than MDs and DOs, 

including podiatrists and chiropractors, and by nonphysician practitioners. We issued a special 

education article on January 20, 2012, through the Medicare Learning Network (MLN) 

“Important Reminder for Providers and Suppliers Who Provide Services and Items Ordered or 

Referred by Other Providers and Suppliers,” reiterating our current policy that portable x-ray 

services can only be ordered by a MD or DO. The article is available at 

http://www.cms.gov/MLNMattersArticles/downloads/SE1201.pdf on the CMS Website. Since 
CMS-1590-P 235 

the publication of the above mentioned article, several stakeholders have told us that members of 

the healthcare community fail to distinguish ordering for portable x-ray services from ordering 

for other diagnostic services where our general policy is to allow nonphysician practitioners and 

physicians other than MDs and DOs to order diagnostic tests within the scope of their authority 

under State law and their Medicare statutory benefit. They report finding the different 

requirements confusing. 

 We propose to revise our current regulations, which limit ordering of portable x-ray 

services to only a MD or DO, to allow other physicians and nonphysician practitioners acting 

within the scope of their Medicare benefit and State law to order portable x-ray services. 

Specifically, we propose revisions to the Conditions for Coverage at §486.106(a) and 

§486.106(b) to permit portable x-ray services to be ordered by a physician or nonphysician 

practitioner in accordance with the ordering policies for other diagnostic services under 

§410.32(a). 

This proposed change would allow a MD or DO, as well as an nurse practitioner, clinical 

nurse specialist, physician assistant, certified nurse-midwife, doctor of optometry, doctor of 

dental surgery and doctor of dental medicine, doctor of podiatric medicine, clinical psychologist, 

and clinical social worker to order portable x-ray services within their State scope of practice and 

the scope of their Medicare benefit. Although all of these physicians and nonphysician 

practitioners are authorized to order diagnostic services in accordance with §410.32(a), their 

Medicare benefit delimits the services that they can provide. 

We also propose to revise the language included in §410.32(c) to recognize the same 

authority for physicians and nonphysician practitioners to order diagnostic tests as is prescribed 

for other diagnostic services in §410.32(a). Finally, we are proposing two technical corrections. 

One is to §410.32(d)(2), where we currently cite to subsection (a)(3) for the definition of 
CMS-1590-P 236 

qualified nonphysician practitioner. The definition of qualified nonphysician practitioner is in 

paragraph (a)(2) and paragraph (a)(3) does not exist; therefore, we are changing the citation to 

the correct citation. The second technical correction is §410.32(b)(2)(iii) to better reflect 

statutory authority to provide neuropsychological testing in addition to psychological testing. 

Although we believe that this proposal is appropriate given overall changes in practice 

patterns since the beginning of the Medicare program, we remain concerned about the OIG’s 

recent findings. The OIG observed questionable billing patterns for portable x-ray services in 

addition to ordering by nonphysician practitioners. Of specific note was the observation that 

some portable x-ray suppliers are delivering services on the same day that the patient also 

receives services in a clinical setting, such as the physician office or hospital. Under our current 

regulation at §486.106(a)(2), the order for portable x-ray services must include a statement 

concerning the condition of the patient which indicates why portable x-ray services are 

necessary. If the patient was able, on the same day that a portable x-ray service was furnished, to 

travel safely to a clinical setting, the statement of need for portable x-ray services could be 

questionable. We also are concerned that the OIG observed some portable x-ray suppliers billing 

for multiple trips to a facility. Medicare makes a single payment for each trip the portable x-ray 

supplier makes to a particular location. We make available multiple modifiers to allow the 

portable x-ray supplier to indicate the number of patients served on a single trip to a facility. We 

expect portable x-ray suppliers to use those modifiers and not to bill multiple trips to the same 

facility when only one trip was made. Additionally, we strongly encourage portable x-ray 

suppliers to make efficient use of resources and consolidate trips rather than making multiple 

trips on the same day as clinically appropriate. 

In conjunction with our proposal to expand the scope of physicians and nonphysician 

practitioners who can order portable x-ray services, we intend to develop, as needed, monitoring 
CMS-1590-P 237 

standards predicated by these and other OIG findings. In addition, we will be conducting data 

analysis of ordering patterns for portable x-ray and other diagnostic services to determine if 

additional claims edits, provider audits, or fraud investigations are required to prevent abuse of 

this service and to allow for the collection of any potential overpayments. We encourage 

providers, as with any diagnostic test, to proactively determine and document the medical 

necessity for this testing. 

We are also considering whether to make other revisions to the current regulations at 42 

CFR, Part 486, Subpart C—Conditions for Coverage: Portable X-Ray Services through future 

rulemaking, as we are aware stakeholders have suggested regulatory changes to consider since 

the last update of this regulation. The last time this regulation was updated was in 2008, but 

many of the sections in Part 486, Subpart C have not been updated since 1995. Since we are 

proposing to update part of Part 486, Subpart C in this proposed rule, we are using this 

opportunity to seek public comment on suggestions for updating in the future the rest of the 

regulations at Part 486, Subpart C. We are open to all suggestions for updates; therefore we did 

not pose specific questions for response by the public. 

We are specifically seeking public comment on suggestions for updating Subpart C—

Conditions for Coverage: Portable X-Ray Services; noting that any regulatory changes would be 

addressed through separate notice-and-comment rulemaking. 
CMS-1590-P 238 

III. Other Provisions of the Proposed Regulation 

A. Ambulance Fee Schedule

1. Amendment to section 1834(l) (13) of the Act 

Section 146(a) of the Medicare Improvements for Patients and Providers Act of 2008 

(Pub. L. 110-275) (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. 

Sections 3105(a) and 10311(a) of the Affordable Care Act further amended section 

1834(l)(13)(A) of the Act to extend the payment add-ons described above for an additional year, 

such that these add-ons also applied to covered ground ambulance transports furnished on or 

after January 1, 2010 and before January 1, 2011. In the CY 2011 PFS final rule (75 FR 73385 

and 73386, 73625), we revised §414.610(c)(1)(ii) to conform the regulations to this statutory 

requirement. 

Section 106(a) of the MMEA again amended section 1834(l)(13)(A) of the Act to extend 

the payment add-ons described above for an additional year, such that these add-ons also applied 

to covered ground ambulance transports furnished on or after January 1, 2011 and before 

January 1, 2012. In the CY 2012 End-Stage Renal Disease Prospective Payment System (ESRD 

PPS) final rule (76 FR 70228, 70284 through 70285, 70315), we revised §414.610(c) (1) (ii) to 
CMS-1590-P 239 

conform the regulations to this statutory requirement. However, in doing so, paragraphs 

(c)(1)(ii)(A) and (B) were inadvertently deleted from the Code of Federal Regulations. 

Therefore, we propose to reinstate paragraphs (c)(1)(ii)(A) and (B), as further revised below to 

conform to subsequent legislation. 

Subsequently, section 306 (a) of the Temporary Payroll Tax Cut Continuation Act of 

2011 (Pub. L. 112-78) (TPTCCA) amended section 1834(l)(13)(A) of the Act to extend the 

payment add-ons described above through February 29, 2012; and section 3007(a) of the Middle 

Class Tax Relief and Job Creation Act of 2012 (Pub. L. 112-96) (MCTRJCA) further amended 

section 1834(l)(13)(A) to extend these payment add-ons through December 31, 2012. Thus, 

these payment add-ons also apply to covered ground ambulance transports furnished on or after 

January 1, 2012 and before January 1, 2013. Accordingly, we are proposing to revise 

§414.610(c)(1)(ii) to conform the regulations to these statutory requirements. These statutory 

requirements are self-implementing. A plain reading of the statute requires only a ministerial 

application of the mandated rate increase, and does not require any substantive exercise of 

discretion on the part of the Secretary. 

2. Amendment to section 146(b) (1) of MIPPA 

Section 146(b) (1) of the MIPPA amended the designation of rural areas for payment of 

air ambulance services. This section originally specified that any area that was designated as a 

rural area for purposes of making payments under the ambulance fee schedule for air ambulance 

services furnished on December 31, 2006, must continue to be treated as a rural area for purposes 

of making payments under the ambulance fee schedule for air ambulance services furnished 

during the period July 1, 2008 through December 31, 2009. 

 Sections 3105(b) and 10311(b) of the Affordable Care Act amended section 146(b)(1) of 

MIPPA to extend this provision for an additional year, through December 31, 2010. In the 
CMS-1590-P 240 

CY 2011 PFS final rule (75 FR 73385 through 86, 73625 through 26), we revised §414.610(h) to 

conform the regulations to this statutory requirement. 

 Section 106(b) of the MMEA amended section 146(b)(1) of MIPPA to extend this 

provision again through December 31, 2011. In the CY 2012 ESRD PPS final rule 

(76 FR 70284 through 70285, 70315), we revised §414.610(h) to conform the regulations to this 

statutory requirement. 

 Subsequently, section 306 (b) of the TPTCCA amended section 146(b)(1) of MIPPA to 

extend this provision through February 29, 2012; and section 3007(b) of the MCTRJCA further 

amended section 146(b)(1) of MIPPA to extend this provision through December 31, 2012. 

Therefore, we are proposing to revise §414.610(h) to conform the regulations to these statutory 

requirements. These statutory requirements are self-implementing. A plain reading of the 

statute requires only a ministerial application of a rural indicator, and does not require any 

substantive exercise of discretion on the part of the Secretary. Accordingly, for areas that were 

designated as rural on December 31, 2006, and were subsequently re-designated as urban, we 

have re-established the “rural” indicator on the ZIP Code file for air ambulance services through 

December 31, 2012. 

3. Amendment to section 1834(l) (12) of the Act 

Section 414 of the Medicare Prescription Drug, Improvement and Modernization Act of 

2003 (MMA) added paragraph (12) to section 1834(l) of 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 
CMS-1590-P 241 

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). 

 Sections 3105(c) and 10311(c) of the Affordable Care Act amended section 

1834(l)(12)(A) of the Act to extend this rural bonus for an additional year through 

December 31, 2010. In the CY 2011 PFS final rule (75 FR 73385 through 73386 and 73625), we 

revised §414.610(c)(5)(ii) to conform the regulations to this statutory requirement. 

 Section 106(c) of the MMEA again amended section 1834(l)(12)(A) of the Act to extend 

the rural bonus described above for an additional year, through December 31, 2011. Therefore, 

in the CY 2012 ESRD PPS final rule (76 FR 70284 through 70285, 70315), we revised 

§414.610(c)(5)(ii) to conform the regulations to this statutory requirement. 

 Subsequently, section 306 (c) of the TPTCCA amended section 1834(l)(12)(A) of the Act 

to extend this rural bonus through February 29, 2012; and section 3007(c) of the MCTRJCA 

further amended section 1834(l)(12)(A) of the Act to extend this rural bonus through December 

31, 2012. 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 on or 

after January 1, 2012 and before January 1, 2013 where transportation originates in a qualified 

rural area.

 This rural bonus is sometimes referred to as the “Super Rural Bonus” and the qualified 
CMS-1590-P 242 

rural areas (also known as “super rural” areas) are identified during the claims adjudicative 

process via the use of a data field included on the CMS supplied ZIP Code File. 

 Accordingly, we are proposing to revise §414.610(c)(5)(ii) to conform the regulations to 

the statutory requirements set forth at section 306(c) of the TPTCCA and section 3007(c) of the 

MCTRJCA. These statutory requirements are self-implementing. Together, these provisions 

require a one-year extension of the rural bonus (which was previously established by the 

Secretary) through December 31, 2012, and does not require any substantive exercise of 

discretion on the part of the Secretary. 

B. Part B Drug Payment: Average Sales Price (ASP) Issues 

Section 1847A of the Act requires use of the average sales price (ASP) payment 

methodology for payment for drugs and biologicals described in section 1842(o)(1)(C) of the Act 

furnished on or after January 1, 2005. The ASP methodology applies to most drugs furnished 

incident to a physician’s service, many drugs furnished under the DME benefit, certain oral 

anti-cancer drugs, and oral immunosuppressive drugs. 

1. Widely Available Market Price (WAMP)/Average Manufacturer Price (AMP) price 

substitution 

 For a drug or biological that is found to have exceeded the WAMP of AMP by a 

threshold percentage, section 1847A(d)(3)(C) of the Act authorizes the Secretary to substitute, 

the lesser of -- 

● The widely available market price for the drug or biological, or 

● 103 percent of the average manufacturer price as determined under section 1927(k)(1) 

of the Act.” 

The applicable threshold percentage is specified in section 1847A(d)(3)(B)(i) of the Act 

as 5 percent for CY 2005. For CY 2006 and subsequent years, section 1847A(d)(3)(B)(ii) of the 
CMS-1590-P 243 

Act authorizes the Secretary to specify the threshold percentage for the WAMP or the AMP, or 

both. In the CY 2006 (70 FR 70222), CY 2007 (71 FR69680), CY 2008 (72 FR 66258), 

CY 2009 (73 FR 69752), and CY 2010 (74 FR 61904) PFS final rules with comment period, we 

specified an applicable threshold percentage of 5 percent for both the WAMP and AMP. We 

based this decision on the fact that data was too limited to support an adjustment to the 5 percent 

threshold. Beginning in CY 2011, we treated the WAMP and AMP based adjustments to the 

applicable threshold percentages separately. 

a. WAMP Threshold and Price Substitution 

After soliciting and reviewing comments, we finalized proposals to continue the 

5 percent WAMP threshold for CY 2011 (75 FR 73469), and CY 2012 (76 FR 73287). For CY 

2013, we again have no additional information from OIG studies or other sources that leads us to 

consider an alternative threshold. When making comparisons to the WAMP, we propose that the 

applicable threshold percentage remain at 5 percent until such time that a change in the threshold 

amount is warranted, and we propose to update §414.904(d)(3)(iv) accordingly. As mentioned 

above, the threshold has remained at 5 percent since 2005. Our proposal will eliminate the need 

for annual rulemaking until a change is warranted. 

We are not proposing to make any WAMP based price substitutions at this time. As we 

noted in the CY 2011 PFS final rule with comment period (75 FR 73470) and reiterated in CY 

2012 (76 FR 73287), we understand that there are complicated operational issues associated with 

the WAMP based substitution policy, and we continue to proceed cautiously in this area. We 

remain committed to providing stakeholders, including providers and manufacturers of drugs 

impacted by potential price substitutions with adequate notice of our intentions, including the 

opportunity to provide input with regard to the processes for substituting the WAMP for the 

ASP. 
CMS-1590-P 244 

b. AMP Threshold 

Like the WAMP threshold, for CY 2013, we have no information that leads us to believe 

that the 5 percent threshold percentage for AMP-based price substitution is inappropriate or 

should be changed. We propose that the applicable threshold percentage remain at 5 percent 

until such time that a change in the threshold amount is warranted, and we propose to update 

§414.904(d)(3)(iii) accordingly. The AMP threshold has remained at 5 percent since 2005. Our 

proposal will eliminate the need for annual rulemaking until a change is warranted. 

c. AMP Price Substitution-Additional condition 

In the CY 2012 PFS rule, we specified that the substitution of AMP for ASP will be made 

only when the ASP exceeds the AMP by 5 percent in two consecutive quarters immediately prior 

to the current pricing quarter, or three of the previous four quarters immediately prior to the 

current quarter, and that matching sets of NDCs had to be used in the comparison (76FR 73289 

through 73295). The value of the AMP based price substation must also be less than the ASP 

payment limit that is calculated for the quarter in which the substitution is applied. 

We did not apply the price substitution policy in April 2012 because access concerns led 

us to reconsider whether it was prudent to proceed with price substitution during a developing 

situation that was related to a drug shortage that had not met the definition of a public health 

emergency under section 1847A(e) of the Act. In light of recent concerns about drug shortages, 

the resulting impact on patient care, beneficiary and provider access, as well as the potential for 

shortages to suddenly affect drug prices for the provider, under the authority in section 

1847A(d)(3)(C) of the Act, we propose adding §414.904(d)(3)(ii)(C) that would prevent the 

AMP price substitution policy from taking effect if the drug and dosage form represented by the 

HCPCS code are reported by the FDA on their Current Drug Shortage list (or other FDA 

reporting tool that identifies shortages of critical or medically necessary drugs) to be in short 
CMS-1590-P 245 

supply at the time that ASP payment limits are being finalized for the next quarter. Further, we 

also would like to clarify that this proposal to add to the safeguards finalized in CY 2012 only 

applies to calculations under the AMP-based price substitution policy. Our proposal is intended 

to continue the cautious approach described in previous rules and to strike a balance between 

operational requirements associated with receiving manufacturers’ ASP reports, calculating the 

payment limits, and posting stable payment limits that will be used to pay claims. We believe 

that this proposal also addresses concerns about access to care, known program issues identified 

by the OIG, and provides an opportunity for some modest program savings. At this time, we are 

not proposing any other changes to the safeguards, timing, or notification that identifies the 

codes that will be substituted each quarter. We welcome comments on our approach as well as 

comments regarding additional specific safeguards for the AMP price substitution policy. 

2. Billing for Part B Drugs Administered Incident to Physicians’ Services. 

In this section, we propose to clarify payment policies regarding billing for certain drugs 

under Medicare Part B. In 2010 and 2011, we issued two change requests (CRs 7109 and 7397) 

that summarized a number of longstanding drug payment policy and billing requirements. We 

considered these CRs to be merely clarifying, rather than changing, our policy. However, one 

item in the CRs, which stated that pharmacies may not bill for drugs that are used incident to 

physicians’ service, has caused some concern. Specifically, we understand that some 

nonphysician suppliers – operating in part on the basis of guidance from a Medicare contractor – 

have been submitting claims for drugs that they have shipped to physicians’ offices for use in 

refilling implanted intrathecal pumps. In light of concern over its potential effect on suppliers, 

we delayed implementation of the most recently updated CR (CR 7397 Transmittal 2437, April 

4, 2012) until January 1, 2013 so that we could undertake rulemaking, evaluate public comments 
CMS-1590-P 246 

on this issue, and determine whether CR 7397 should be implemented as planned, revised, or 

rescinded. 

Implanted pumps may qualify as Durable Medical Equipment (DME); however, unlike 

external pumps used to administer drugs, implanted pumps are typically refilled in a physician’s 

office. The implanted intrathecal pump is refilled by injecting the drug into a pump’s reservoir, 

which lies below the patient’s skin. The reservoir is connected to the pump, which delivers the 

drug to the intrathecal space through a tunneled catheter. The procedure of refilling an 

intrathecal pain pump is a service that is typically performed by the physician because of risk and 

complexity. 

To be covered by Medicare, an item or service must fall within one or more benefit 

categories within Part A or Part B, and must not be otherwise excluded from coverage. Drugs 

and biologicals paid under Medicare part B drugs fall into three basic categories as follows: 

● Drugs furnished “incident to” a physician’s services: These are typically injectable 

drugs that are bought by the physician, administered in the physician’s office and then billed by 

the physician to the Medicare Administrative Contractor (MAC). 

● Drugs administered through a covered item of DME: These drugs are supplies 

necessary for the effective use of DME and are typically furnished to the beneficiary by suppliers 

that are either pharmacies (or general DME suppliers that utilize licensed pharmacists) for 

administration in a setting other than the physician’s office. Most DME drugs are billed to the 

DME MAC. 

● Drugs specified by the statute: Include a variety of drugs, such as oral 

immunosuppressives and certain vaccines. 

Drugs used to refill an implanted intrathecal pump can be considered to be within either 

the “incident to” or the DME benefit category. The CMS Benefit Policy Manual (100-02 
CMS-1590-P 247 

Chapter 15 Section 50.3) states that drugs paid under the “incident to” provision are of a form 

that is not usually self-administered; are furnished by a physician; and are administered by the 

physician, or by auxiliary personnel employed by the physician and under the physician’s 

personal supervision. In what we believe is a typical situation, when physicians’ services are 

used to refill an intrathecal pump, the “incident to” requirements can be met because, consistent 

with our guidance and longstanding policy, the physician or other professional employed by his 

or her office performs a procedure to inject the drug into the implanted pump’s reservoir (that is, 

the drug is not self-administered) and the drug represents a cost to the physician because he or 

she has purchased it. 

Conversely, we believe that in the typical situation, payment to a pharmacy or other 

nonphysician supplier under the DME benefit for a drug dispensed for use in the physician’s 

office is both inappropriate and inconsistent with existing guidance. For example, DME 

prosthetics, orthotics, and supplies (POS) policy does not permit payment for prosthetics 

dispensed prior to a procedure. Moreover, in the case of prescription drugs used in conjunction 

with DME, our guidance is clear that the entity that dispenses the drug needs to furnish it directly 

to the patient for whom a prescription is written. We do not believe that an arrangement 

whereby a pharmacy (or supplier) ships a drug to a physician’s office for administration to a 

patient constitutes furnishing the drug directly to the patient. 

We note that payment to pharmacies (or suppliers) for drugs used to refill an implanted 

pump can be made under the DME benefit category where the drug is dispensed to a patient and 

the implanted pump is refilled without a physician’s service. However, it is our understanding 

that implanted pumps are rarely refilled without utilizing the service of a physician. 

We are concerned about stakeholders’ reports that, due to guidance from a contractor, 

Medicare payment policy on this issue has been applied in an inconsistent manner. We consider 
CMS-1590-P 248 

the contractor’s guidance to be erroneous. This inconsistency has permitted supplier claims for 

drugs dispensed by pharmacies to physicians’ offices to be paid in some jurisdictions and has 

denied such payment in others. We understand that the inconsistent application of our payment 

policy has influenced the business and professional practices of pharmacies/DME suppliers that 

prepare drugs for implanted pumps. However, we do not believe that payment for drugs used to 

refill implanted DME should continue to be made because such action is not supported under 

long standing policy and, as discussed above, is not appropriate. 

We therefore propose to clarify that we consider drugs used by a physician to refill an 

implantable item of DME to be within the “incident to” benefit category and not the DME 

benefit category. Therefore, the physician must buy and bill for the drug, and a non-physician 

supplier that has shipped the drug to the physician’s office may not do so (except as may be 

permitted pursuant to a valid reassignment). We welcome comments on this proposal and its 

potential impact on beneficiaries and providers. 
CMS-1590-P 249 

C. Durable Medical Equipment (DME) Face-to-Face Encounters and Written Orders Prior to 

Delivery

1. Background 

Sections 1832, 1834, and 1861 of the Act establish that the provision of durable medical 

equipment, prosthetic, orthotics, and supplies (DMEPOS) is a covered benefit under Part B of 

the Medicare program. 

Section 1834(a)(11)(B)(i) of the Act, as redesignated by the Affordable Care Act, 

authorizes us to require, for specified covered items, that payment may only be made under 

section 1834(a) of the Act if a physician has communicated to the supplier a written order for the 

item, before delivery of the item. Section 1834(h)(3) of the Act states that section 1834(a)(11) 

applies to prosthetic devices, orthotics, and prosthetics in the same manner as it applies to items 

of durable medical equipment (DME). In a December 7, 1992 final rule (57 FR 57675), we 

implemented this provision in §410.38(g), for DME items and §410.36(b) for prosthetic devices, 

orthotics, and prosthetics. Both of these sections state that as a requirement for payment, CMS, a 

carrier, or, more recently, a Medicare Administrative Contractor (MAC) may determine that an 

item of DME requires a written physician order before delivery. In addition to our regulations at 

§410.38(g) and §410.36(b), we have stated in Chapter 5, Section 5.2.3.1 of the Program Integrity 

Manual, that the following items require a written order prior to delivery: (1) pressure reducing 

pads, mattress overlays, mattresses, and beds; (2) seatlift mechanisms; (3) transcutaneous 

electrical nerve stimulation (TENS) units; (4) power operated vehicles (POVs) and power 

wheelchairs. 

Section 6407(b) of the Affordable Care Act amended section 1834(a)(11)(B) of the Act. 

It added language that requires a written order for certain items of DME, which under section 

1834(h)(3) of the Act also could include prosthetic devices, orthotics, and prosthetics, to be 
CMS-1590-P 250 

issued per a physician documenting that a physician, a physician assistant (PA), a nurse 

practitioner (NP), or a clinical nurse specialist (CNS) has had a face-to-face encounter with the 

beneficiary. The encounter must occur during the 6 months prior to the written order for each 

item or during such other reasonable timeframe as specified by the Secretary. 

2. Provisions of the Proposed Regulations 

a. DME Face-to-Face Encounters 

(1) General Requirements 

We are proposing to first revise §410.38(g) to require, as a condition of payment for 

certain covered items of DME, that a physician must have documented and communicated to the 

DME supplier that the physician or a PA, an NP, or a CNS has had a face-to-face encounter with 

the beneficiary no more than 90 days before the order is written or within 30 days after the order 

is written. 

We make this proposal because we believe that a face-to-face encounter that occurs 

within 90 days prior to the written order for DME should be relevant to the reason for the 

beneficiary's need for the item of DME, and therefore, this face-to-face encounter should 

substantiate that the beneficiary's condition warrants the covered item of DME and be sufficient 

to meet the goals of this statutory requirement. However, we recognize that there may be 

circumstances when it may not be possible to meet this general requirement of "prior to the 

written order," and that in such cases, beneficiary access to needed items must be protected. If a 

face-to-face encounter occurs within 90 days of the written order, but is not related to the 

condition warranting the need for the item of DME, or if the beneficiary has not seen the 

physician or PA, NP, or CNS within the 90 days prior to the written order, we propose to allow a 

face-to-face encounter up to and including 30 days after the order is written in order to ensure 

access to needed items. 
CMS-1590-P 251 

During the face-to-face encounter the physician, a PA, a, NP, or a CNS must have 

evaluated the beneficiary, conducted a needs assessment for the beneficiary or treated the 

beneficiary for the medical condition that supports the need for each covered item of DME. As a 

matter of practice, this information would be part of the beneficiary's medical record, which 

identifies the practitioner who provided the face-to-face assessment. We believe that requiring a 

face-to-face encounter that supports the need for the covered item of DME would reduce the risk 

of fraud, waste, and abuse since these visits would help ensure that a beneficiary's condition 

warrants the covered item of DME. 

Section 1834(a)(11)(B)(ii) of the Act, as amended by section 6407(b) of the Affordable 

Care Act states that a physician must document that the physician, a PA, a NP, or a CNS has had 

a face-to-face encounter (other than with respect to encounters that are incident to services 

involved) with the beneficiary. Incident to services are defined in section 1861(s)(2)(A) of the 

Act. Likewise, for the purpose of this regulation, a face-to-face encounter must be documented 

by a physician and any encounter that is covered as an "incident to" service does not satisfy the 

requirements of this regulation. 

We note that a face-to-face encounter may be accomplished via a telehealth encounter if 

all Medicare telehealth requirements as defined under section 1834(m) of the Act and the 

implementing regulations in §410.78 and §414.65 are met. Specifically, Medicare telehealth 

services can only be furnished to an eligible telehealth beneficiary in an originating site. The 

requirements in this proposed rule do not supersede the requirements of telehealth and merely 

apply to the telehealth benefit where applicable. In general, originating sites must be located in a 

rural health professional shortage area (HPSA) or in a county outside of a metropolitan statistical 

area (MSA). The practitioner at the distant site may be a physician, PA, NP, or CNS, and the 

encounter must be reported with a healthcare procedure common coding system (HCPCS) code 
CMS-1590-P 252 

for a service on the list of approved Medicare telehealth services for the applicable year. In the 

May 5, 2010 Federal Register (76 FR 25550), we published a final rule that revised the 

conditions of participation (CoPs) for hospitals and critical access hospitals (CAHs). These 

revisions implement a new credentialing and privileging process for physicians and other 

practitioners providing telemedicine services. We refer readers to the CMS Website for more 

information regarding telehealth services at http://www.cms.gov/Telehealth/. 

A single face-to-face encounter, including those facilitated through the appropriate use of 

telehealth, can support the need for multiple covered items of DME as long as it is clearly 

documented in the pertinent medical record that the beneficiary was evaluated or treated for a 

condition that supports the need for each covered item of DME, during the specified period of 

time. 

To promote the authenticity and comprehensiveness of the written order and as part of 

our efforts to reduce the risk of waste, fraud, and abuse, we propose that as a condition of 

payment a written order must include: (1) the beneficiary name; (2) the item of DME ordered; 

(3) prescribing practitioner NPI; (4) the signature of the prescribing practitioner; (5) the date of 

the order; (6) the diagnosis; and (7) necessary proper usage instructions, as applicable. Examples 

of necessary proper usage instruction could include duration of use, method of utilization, and 

correct positioning. We recognize that standards of practice may require that orders contain 

additional information. However, for purposes of this proposed rule, which is focused on 

implementing section 1834(a)(11)(B) of the Act and reducing fraud, waste, and abuse, an order 

without these minimum elements would be considered incomplete and would not support a claim 

for payment. We believe including this information on the written order would be a safeguard 

against waste, fraud, and abuse by promoting authenticity and comprehensiveness of the order by 

the practitioner. 
CMS-1590-P 253 

Based on our commitment to the general principles of the President's Executive Order 

entitled "Improving Regulation and Regulatory Review” (released January 18, 2011) and to be 

consistent with other provisions in the amendments made by section 6407(a) of the Affordable 

Care Act and the provisions of section 6407 (d) of the Affordable Care Act as discussed above, 

we are proposing to require that the face-to-face encounter occur no earlier than 90 days prior to 

each written order for a covered item of DME or within 30 days after the order is written. This 

proposal is consistent with the Medicare and Medicaid home health face-to-face requirement 

which increases physician accountability and specifies a timeframe within the discretion of the 

Secretary. (For more information on the Medicare and Medicaid home health face-to-face 

requirements see the November 17, 2010 final rule (75 FR 70372) and the July 12, 2011 

proposed rule (76 FR 41032) for Medicare and Medicaid respectively.) We have exercised our 

discretion to set a timeframe other than 6 months because we believe that our proposal strikes an 

appropriate balance among several factors: (1) the potential for fraud, waste, abuse associated 

with certain DME items; (2) the potential inconvenience and cost to practitioners and 

beneficiaries; and (3) potential health benefits to beneficiaries from increased practitioner 

involvement and more periodic reviews of their status and progress. 

We perform ongoing education on many topics including the requirements of the other 

face-to-face provisions. This education includes, but is not limited to, various Medicare 

Learning Network® products such as MLN Matters® articles, brochures, fact sheets, Web-based 

training courses, and podcasts; Open Door forums; and national provider conference calls. 

Medicare is already working proactively with home health agencies, physicians, and other 

providers to educate them on implementing the face-to-face requirement. We plan to conduct 

similar provider education and outreach in implementing the DME face-to-face requirement. 

As noted previously, section 1834(h)(3) of the Act adds prosthetic devices, orthotics, and 
CMS-1590-P 254 

prosthetics to the items encompassed by section 1834(a)(11)(B) of the Act. At this time, we are 

not proposing changes to §410.36(b) to require documentation of a face-to-face encounter for 

prosthetic devices, orthotics, and prosthetics that, according to §410.36(b), require a written 

order before delivery in this proposed rule. We intend to use future rulemaking to determine 

which prosthetic devices, orthotics, and prosthetics, require, as a condition of payment, a written 

order before delivery supported by documentation of a face-to-face encounter with the 

beneficiary consistent with section 1834(a)(11)(B)(ii) of the Act. We welcome comments on 

including prosthetic devices, orthotics, and prosthetics in future rulemaking, including any 

criteria that should be used for determining what items should require a written order before 

delivery supported by documentation of a face-to-face encounter. 

This proposed requirement does not supersede any regulatory requirements that more 

specifically address a face-to-face encounter requirement for a particular item of DME. For 

example, §410.38(c), which implemented section 1834(a)(1)(E)(iv) of the Act, specifically 

addresses prescription and face-to-face encounter requirements for power mobility devices 

(PMDs) and uses a 45-day period between the date of the face-to-face encounter and the date of 

the written order. That requirement is specific to the unique factors, including equipment 

expense and complex medical necessity determinations that affect PMDs. 

(2) Physician Documentation 

The statute requires that a physician document that the physician or a PA, NP or CNS has 

had a face-to-face encounter with the beneficiary. We propose that when the face-to-face 

encounter is performed by a physician, the submission of the pertinent portion(s) of the 

beneficiary’s medical record, containing sufficient information to document that the face-to-face 

encounter meets our requirements, would be considered sufficient and valid documentation of 

the face-to-face encounter when submitted to the supplier and made available to CMS or its 
CMS-1590-P 255 

agents upon request. Some examples of pertinent parts of the beneficiary's medical record that 

can demonstrate that a face-to-face encounter has occurred can include: history; physical 

examination; diagnostic tests; summary of findings; diagnoses; treatment plans; or other 

information as appropriate. As an alternative, we are requesting comments on a second option 

for physicians to document the face-to-face encounter when it is performed by the physician, by 

requiring this physician documentation to be identical to what is required for a PA, a NP, or a 

CNS as discussed later in this section. We strive to find the option that strikes a balance between 

minimizing the effect on physicians, while still meeting the statutory objective to limit fraud, 

waste, and abuse. 

(3) Physician Documentation of Face-to-Face Encounters Performed by a Physician Assistant, 

Nurse Practitioner, or Clinical Nurse Specialist 

We are considering the following proposed options for physician documentation of a 

face-to-face encounter performed by a PA, NP, or CNS. We are reserving judgment as to which 

of these proposed options best accomplishes our goals until the final regulation and have not 

provided language reflecting these options in the proposed regulations text. The options are as 

follows: 

● Option 1: Attestation stating: "I, Doctor (Name) (NPI number) have reviewed the 

medical record and attest that (PA, NP or CNS) has performed a face-to-face encounter with 

(beneficiary) on (date) and evaluated the need for (the item of DME)." (Sign)(Date). This 

option would provide all the needed information to document that a face-to-face encounter has 

occurred between the PA, NP or CNS and the beneficiary in a standardized manner. However, 

this attestation would not eliminate the need for the medical record to support the medical 

necessity of the ordered item. The attestation serves only as physician documentation of the 

face-to-face encounter. 
CMS-1590-P 256 

● Option 2: The physician signs or cosigns the pertinent portion of the medical record, 

for the beneficiary for the date of the face-to-face encounter, thereby documenting that the 

beneficiary was evaluated or treated for a condition relevant to an item of DME on that date of 

service. This option would provide evidence that the physician has reviewed the relevant 

documentation to support that a face-to-face encounter occurred for that date of service. A 

signed order by the physician alone would not satisfy the requirement described in this option 

that the physician "sign/cosign the pertinent portion of the medical record." 

● Option 3: The physician specifically initials the history and physical examination for 

the beneficiary for the date of the face-to-face encounter, thereby documenting that the 

beneficiary was evaluated or treated for a condition relevant to an item of DME on that date of 

service. This option would provide evidence that the physician has reviewed the relevant 

documentation to support that a face-to-face encounter occurred for that date of service. A 

signed order would not satisfy the requirement described in this option that the physician "initial 

the history and physical examination for the beneficiary for the date of the face-to-face 

encounter". 

We welcome comment on how physician documentation requirements should be handled 

when the face-to-face encounter with the beneficiary is conducted by a PA, a NP, or a CNS. We 

are looking for the alternative that best accomplishes the objective of reducing waste, fraud, and 

abuse by having a physician document the face-to-face encounter if it is performed by a PA, NP, 

or CNS without creating undue impact. 

(4) Supplier Notification 

Since the supplier submits the claims for the covered items of DME, the supplier must 

have access to the documentation of the face-to-face encounter. We welcome comment on the 

type of communication that should occur between the physician or PA, NP, or CNS, and the 
CMS-1590-P 257 

supplier. All documentation to support the appropriateness of the item of DME ordered 

including documentation of the face-to-face encounter, must be available to the supplier. As 

with all items and services, we require both the ordering practitioner and the supplier to maintain 

access to the written order and supporting documentation relating to written orders for covered 

items of DME and provide them to us upon our request or at the request of our contractors. 

We are considering adding one of the following proposed options on how documentation 

of the face-to-face encounter must be delivered to the supplier. We are reserving judgment on 

these proposed options until the final regulation. The options are as follows: 

● Option 1: Require the practitioner who wrote the order to provide the physician 

documentation of the face-to-face encounter directly to the DME supplier. This option may 

increase practitioner accountability, since it requires practitioners to submit the required 

documentation to the supplier. 

● Option 2: Require the physician who completes the documentation of the face-to-face 

encounter to provide that documentation directly to the DME supplier. This option is consistent 

with current policies where the entity who submits the claims collects the necessary 

documentation even if it comes from multiple sources. For example, the supplier must have 

access to all documentation necessary to support the claim upon request. 

● Option 3: Require that the documentation, no matter who completes it, be provided to 

the DME supplier through the same process as the written order for the covered item of DME. 

The option ensures that the same pathway followed for the order is also followed for the face-toface documentation. In most circumstances, we would expect the order and the face-to-face 

documentation to travel together, the exception being those circumstances where the face-to-face 

encounter was conducted after the order. 
CMS-1590-P 258 

● Option 4: Require a physician to provide a copy of the face-to-face documentation to 

the beneficiary for the beneficiary to deliver to the DME supplier of his or her choice. This 

would ensure that the supplier receives the documentation of the face-to-face encounter directly 

and limits the supplier’s need to rely on the PA, NP, or CNS to receive this documentation 

completed by the physician. 

We welcome comment on these options in order to facilitate open communication and 

enhanced coordination of documentation of a face-to-face encounter between the supplier, 

physician or when applicable, the PA, NP or CNS. 

b. Covered Items 

Section 1834(a)(11)(B)(i) of the Act (as redesignated by the Affordable Care Act 

authorizes us to specify covered items that require a written order prior to delivery of the item. 

Under section 1834(a)(11)(B)(ii) of the Act, these orders must be written pursuant to a physician 

documenting that a face-to-face encounter has occurred. Accordingly, to reduce the risk of 

fraud, waste, and abuse, we are proposing a list of Specified Covered Items that would require a 

written order prior to delivery. Our proposed list of Specified Covered Items is below. In future 

years, updates to this list would appear annually in the Federal Register and the full updated list 

would be available on the CMS Website. 

As highlighted in the January 2007 Government Accountability Office (GAO) report 

entitled, "Improvements Needed to Address Improper Payments for Medical Equipment and 

Supplies" it is estimated that there were $700 million in improper payments across the spectrum 

of DMEPOS from April 1, 2005, through March 31, 2006. GAO did not specifically recommend 

the use of DME face-to-face encounters as a remedial action in its report. However, the GAO 

did recommend making improvements to address improper payments in the DMEPOS arena. 

This proposed rule is one way in which we are working to prevent improper payments. 
CMS-1590-P 259 

Though we initially considered making all items encompassed by section 1834(a)(11)(B) 

of the Act (including prosthetic and orthotic items described in section 1834(h)(3) of the Act) 

subject to a face-to-face encounter requirement, we have first proposed a more limited criteria 

driven list to balance what we believe to be broad statutory intent to establish a face-to-face 

requirement to prevent waste, fraud, and abuse with concerns that including all items could have 

an undue negative effect on practitioners and suppliers. We welcome comment on limiting the 

associated burden of this proposed rule by refining the number of items subject to a face-to-face 

encounter, while still protecting the Medicare Trust Funds. 

In this section of the proposed rule, we describe our proposed criteria, as well as the 

reasons we selected these criteria. We first note that our proposed list of Specified Covered 

Items contains DME items only. We intend to use future rulemaking to apply section 

1834(a)(11)(B)(ii) of the Act to prosthetics and orthotics. We believe that our proposed current 

focus on DME items is an appropriate way of balancing our goals of reducing waste, fraud, and 

abuse and limiting burden on beneficiaries and the supplier community. 

We propose to focus initially on DME items for several reasons. First, these items are 

often marketed directly to beneficiaries and requiring a face-to-face encounter would help ensure 

that a practitioner has met with the beneficiary and considered whether the item is appropriate. 

Additionally, requiring a face-to-face encounter would help ensure that practitioners who order 

DME items are familiar with the beneficiary's medical condition, that this condition is 

documented, and that the item is reasonable and necessary. Although we are also concerned 

about fraud, waste, and abuse associated with prosthetics and prosthetic devices, these items are, 

as stated in the Medicare Claims Processing Manual Chapter 20 (Section 10.1.2) "devices that 

replace all or part of an internal body organ or replace all or part of the function of a permanently 

inoperative or malfunctioning internal body organ." The body member that is being replaced by 
CMS-1590-P 260 

the prosthetic device can often be identified based on previous claims history. We will consider 

this separately as there may be different burden issues and other considerations that apply. 

Therefore we are not pursuing a face-to-face requirement on these items at this time. Further, 

since orthotics are treated in a manner similar to prosthetics for billing and coverage purposes, in 

order to apply consistent criteria these items will be considered together for future rulemaking. 

We welcome comment on limiting the associated burden of this proposed regulation by 

refining the number of items subject to a face-to-face encounter, while still protecting the 

Medicare Trust Funds and also meeting the requirements of the statute. 

The proposed list of Specified Covered Items contains items that meet at least one of the 

following four criteria: (1) items that currently require a written order prior to delivery per 

instructions in our Program Integrity Manual; (2) items that cost more than $1,000; (3) items that 

we, based on our experience and recommendations from the DME MACs, believe are 

particularly susceptible to fraud, waste, and abuse; (4) items determined by CMS as vulnerable to 

fraud, waste and abuse based on reports of the HHS Office of Inspector General, Government 

Accountability Office or other oversight entities. 

We are proposing to include items already listed in the Program Integrity Manual (PIM), 

Chapter 5, section 5.2.3.1. These items were added to the PIM originally since they were seen as 

posing vulnerabilities to the Medicare program that could be mitigated through requiring a 

written order prior to delivery. We believe that requiring a face-to-face encounter is consistent 

with our previous initiatives and strengthens our efforts to address this vulnerability. 

We are also proposing to include any items of DME with a price ceiling greater than or 

equal to $1,000 in the price ceiling column on the DMEPOS Fee Schedule, which is updated 

annually and lists Medicare allowable pricing for DME. We believe that improper claims related 

to these high dollar items have a greater effect on the Medicare Trust Funds based on amounts 
CMS-1590-P 261 

paid by Medicare for these items. Therefore, any items that are $1,000 or greater would be 

added annually to the list of Specified Covered Items on a prospective basis. For administrative 

simplicity we would not annually adjust this value for inflation, any changes to this threshold 

will go through rulemaking. We see this price point as striking a balance between our 

responsibility to protect the Medicare Trust Funds and ensuring these requirements do not place 

an additional burden on beneficiaries, practitioners, and suppliers. Our objective is to minimize 

inappropriate use of high dollar DME items to help protect and preserve the Medicare Trust 

Funds. 

The third criterion added items that we believe, based on our experience and 

recommendations from our DME Medicare MACs are particularly susceptible to fraud, waste, 

and abuse. Based on their experience, the DME MACs suggested items that warrant increased 

practitioner involvement because these items are often marketed directly to beneficiaries, thus 

highlighting the important role of the practitioner in conducting a needs assessment, evaluating, 

or treating the beneficiary to ensure that his/her condition warrants the item. The evaluations 

may assist in ensuring that the DME items are medically necessary for the beneficiary. 

Increasing the practitioner's role in evaluating the beneficiary's need for such items, would help 

ensure proper ordering of DME items, thereby minimizing the risk of waste, fraud, and abuse. 

The items recommended by the DME contractors were pressure reducing pads, mattress 

overlays, mattress, beds, seat lift mechanisms, TENS units, AEDs, external infusion pumps, 

glucose monitors, wheelchairs and wheelchair accessories, nebulizers, negative pressure wound 

therapy pumps, oxygen and oxygen equipment, pneumatic compression devices, positive airway 

pressure devices, respiratory assists devices, and cervical traction devices. 

This criterion was also influenced by our experience with the Health Care Fraud and 

Prevention and Enforcement Action Teams (HEAT). These teams were established by HHS and 
CMS-1590-P 262 

the Department of Justice (DOJ) to investigate, among other things, fraudulent DME suppliers 

and have recovered millions of dollars in DME fraud. The HEAT strike force teams, which are 

now in nine cities nationwide, have assisted in investigating and prosecuting DME suppliers who 

were fraudulently seeking payment for DME items and services. HEAT investigations have 

resulted in indictments against DME suppliers relating to the following items: pressure reducing 

mattresses, oxygen equipment, manual wheelchairs, hospital beds, infusion supplies, and 

nebulizers. Further information about DME fraud by State is available at 

www.stopmedicarefraud.gov.

We are also proposing the inclusion of certain items of DME on the list of Specified 

Covered Items because OIG has expressed concerns (as expressed in DHHS-OIG reports since 

1999) that these items are vulnerable to fraud, waste and abuse. These reports detailed 

vulnerabilities and called for CMS to address these issues. For example, in an OIG Report 

entitled "Inappropriate Medicare Payments for Pressure Reducing Support Surfaces" (OEI-02-

07-00420), the OIG noted as a vulnerability the fact that the vast majority of pressure reducing 

pads that were billed failed to meet the coverage criteria. Home oxygen therapy was highlighted 

as a vulnerability in the OIG Report entitled "Usage and Documentation of Home Oxygen 

Therapy" (OEI-03-96-00090). Documentation and communication problems associated with 

negative pressure wound therapy pumps were highlighted in a report titled "Comparison of 

Prices for Negative Pressure Wound Therapy Pumps" (OEI-02-07-00660). As the OIG 

explained in that report, " [s]uppliers are required to communicate with the beneficiary's treating 

clinician to assess wound healing progress and to determine whether the beneficiary continues to 

qualify for Medicare coverage of the pump . . . [S]uppliers reported not having contact with 

clinicians for almost one-quarter of the beneficiaries. " 

Our proposed list of Specified Covered Items is in Table 24 of this proposed rule. We 
CMS-1590-P 263 

further propose to update this list of Specified Covered Items annually in order to add any new 

items that are described by a HCPCS code for the following types of DME: 

● TENS unit 

● Rollabout chair 

● Manual Wheelchair accessories 

● Oxygen and respiratory equipment 

● Hospital beds and accessories 

● Traction-cervical 

Note that the proposed list does not include power mobility devices, which are subject to 

already existing face-to-face requirements, as previously discussed. In addition, we propose to 

add to the list any item of DME that in the future appears on the DMEPOS Fee Schedule with a 

price ceiling at or greater than $1,000. Items not included in one of the proposed automatic 

pathways would be added to the list of Specified Covered Items through notice and comment 

rulemaking. 

Through updates in the Federal Register, we propose removing HCPCS codes from the 

list that are no longer covered by Medicare or that are discontinued HCPCS codes. 

TABLE 24: DME List of Specified Covered Items 

HCPCS 

Code Description 

E0185 Gel or gel-like pressure mattress pad 

E0188 Synthetic sheepskin pad 

E0189 Lamb's wool sheepskin pad 

E0194 Air fluidized bed 

E0197 Air pressure pad for mattress standard length and width 

E0198 Water pressure pad for mattress standard length and width 

E0199 Dry pressure pad for mattress standard length and width 

E0250 Hospital bed fixed height with any type of side rails, mattress 

E0251 Hospital bed fixed height with any type side rails without mattress 

E0255 Hospital bed variable height with any type side rails with mattress 

E0256 Hospital bed variable height with any type side rails without mattress 

E0260 Hospital bed semi-electric (Head and foot adjustment) with any type 
CMS-1590-P 264 

HCPCS 

Code Description 

side rails with mattress 

E0261 

Hospital bed semi-electric (head and foot adjustment) with any type 

side rails without mattress 

E0265 

Hospital bed total electric (head, foot and height adjustments) with 

any type side rails with mattress 

E0266 

Hospital bed total electric (head, foot and height adjustments) with 

any type side rails without mattress 

E0290 Hospital bed fixed height without rails with mattress 

E0291 Hospital bed fixed height without rail without mattress 

E0292 Hospital bed variable height without rail without mattress 

E0293 Hospital bed variable height without rail with mattress 

E0294 

Hospital bed semi-electric (head and foot adjustment) without rail 

with mattress 

E0295 

Hospital bed semi-electric (head and foot adjustment) without rail 

without mattress 

E0296 

Hospital bed total electric (head, foot and height adjustments) 

without rail with mattress 

E0297 

Hospital bed total electric (head, foot and height adjustments) 

without rail without mattress 

E0300 Pediatric crib, hospital grade, fully enclosed 

E0301 

Hospital bed Heavy Duty extra wide, with weight capacity 350-600 

lbs with any type of rail, without mattress 

E0302 

Hospital bed Heavy Duty extra wide, with weight capacity greater 

than 600 lbs with any type of rail, without mattress 

E0303 

Hospital bed Heavy Duty extra wide, with weight capacity 350-600 

lbs with any type of rail, with mattress 

E0304 

Hospital bed Heavy Duty extra wide, with weight capacity greater 

than 600 lbs with any type of rail, with mattress 

E0424 

Stationary compressed gas Oxygen System rental; includes contents, 

regulator, nebulizer, cannula or mask and tubing 

E0431 

Portable gaseous oxygen system rental includes portable container, 

regulator, flowmeter, humidifier, cannula or mask, and tubing 

E0433 Portable liquid oxygen system 

E0434 

Portable liquid oxygen system, rental; includes portable container, 

supply reservoir, humidifier, flowmeter, refill adaptor, content gauge, 

cannula or mask, and tubing 

E0439 

Stationary liquid oxygen system rental, includes container, contents, 

regulator, flowmeter, humidifier, nebulizer, cannula or mask, and 

tubing 

E0441 Oxygen contents, gaseous (1 months supply) 

E0442 Oxygen contents, liquid (1 months supply) 

E0443 Portable Oxygen contents, gas (1 months supply) 

E0444 Portable oxygen contents, liquid (1 months supply) 

E0450 Volume control ventilator without pressure support used with 
CMS-1590-P 265 

HCPCS 

Code Description 

invasive interface 

E0457 Chest shell 

E0459 Chest wrap 

E0460 Negative pressure ventilator portable or stationary 

E0461 

Volume control ventilator without pressure support node for a 

noninvasive interface 

E0462 Rocking bed with or without side rail 

E0463 

Pressure support ventilator with volume control mode used for 

invasive surfaces 

E0464 

Pressure support vent with volume control mode used for 

noninvasive surfaces 

E0470 

Respiratory Assist Device, bi-level pressure capability, without 

backup rate used non-invasive interface 

E0471 

Respiratory Assist Device, bi-level pressure capability, with backup 

rate for a non-invasive interface 

E0472 

Respiratory Assist Device, bi-level pressure capability, with backup 

rate for invasive interface 

E0480 Percussor electric/pneumatic home model 

E0482 

Cough stimulating device, alternating positive and negative airway 

pressure 

E0483 High Frequency chest wall oscillation air pulse generator system 

E0484 Oscillatory positive expiratory device, non-electric 

E0570 Nebulizer with compressor 

E0575 Nebulizer, ultrasonic, large volume 

E0580 

Nebulizer, durable, glass or autoclavable plastic, bottle type for use 

with regulator or flowmeter 

E0585 Nebulizer with compressor & heater 

E0601 Continuous airway pressure device 

E0607 Home blood glucose monitor 

E0627 Seat lift mechanism incorporated lift-chair 

E0628 Separate Seat lift mechanism for patient owned furniture electric 

E0629 Separate seat lift mechanism for patient owned furniture non-electric 

E0636 

Multi positional patient support system, with integrated lift, patient 

accessible controls 

E0650 Pneumatic compressor non-segmental home model 

E0651 

Pneumatic compressor segmental home model without calibrated 

gradient pressure 

E0652 

Pneumatic compressor segmental home model with calibrated 

gradient pressure 

E0655 

Non- segmental pneumatic appliance for use with pneumatic 

compressor on half arm 

E0656 

Non- segmental pneumatic appliance for use with pneumatic 

compressor on trunk 
CMS-1590-P 266 

HCPCS 

Code Description 

E0657 

Non- segmental pneumatic appliance for use with pneumatic 

compressor chest 

E0660 

Non- segmental pneumatic appliance for use with pneumatic 

compressor on full leg 

E0665 

Non- segmental pneumatic appliance for use with pneumatic 

compressor on full arm 

E0666 

Non- segmental pneumatic appliance for use with pneumatic 

compressor on half leg 

E0667 

Segmental pneumatic appliance for use with pneumatic compressor 

on full-leg 

E0668 

Segmental pneumatic appliance for use with pneumatic compressor 

on full arm 

E0669 

Segmental pneumatic appliance for use with pneumatic compressor 

on half leg 

E0671 Segmental gradient pressure pneumatic appliance full leg 

E0672 Segmental gradient pressure pneumatic appliance full arm 

E0673 Segmental gradient pressure pneumatic appliance half leg 

E0675 

Pneumatic compression device, high pressure, rapid 

inflation/deflation cycle, for arterial insufficiency 

E0692 Ultraviolet light therapy system panel treatment 4 foot panel 

E0693 Ultraviolet light therapy system panel treatment 6 foot panel 

E0694 Ultraviolet multidirectional light therapy system in 6 foot cabinet 

E0720 

Transcutaneous electrical nerve stimulation, two lead, local 

stimulation 

E0730 

Transcutaneous electrical nerve stimulation, four or more leads, for 

multiple nerve stimulation 

E0731 Form fitting conductive garment for delivery of TENS or NMES 

E0740 

Incontinence treatment system, Pelvic floor stimulator, monitor, 

sensor, and/or trainer 

E0744 Neuromuscular stimulator for scoliosis 

E0745 Neuromuscular stimulator electric shock unit 

E0747 

Osteogenesis stimulator, electrical, non-invasive, other than spine 

application. 

E0748 Osteogenesis stimulator, electrical, non-invasive, spinal application 

E0749 Osteogenesis stimulator, electrical, surgically implanted 

E0760 Osteogenesis stimulator, low intensity ultrasound, non-invasive 

E0762 

Transcutaneous electrical joint stimulation system including all 

accessories 

E0764 

Functional neuromuscular stimulator, transcutaneous stimulations of 

muscles of ambulation with computer controls 

E0765 FDA approved nerve stimulator for treatment of nausea & vomiting 

E0782 Infusion pumps, implantable, Non-programmable 

E0783 Infusion pump, implantable, Programmable 

E0784 External ambulatory infusion pump 
CMS-1590-P 267 

HCPCS 

Code Description 

E0786 Implantable programmable infusion pump, replacement 

E0840 Tract frame attach to headboard, cervical traction 

E0849 

Traction equipment cervical, free-standing stand/frame, pneumatic, 

applying traction force to other than mandible 

E0850 Traction stand, free standing, cervical traction 

E0855 Cervical traction equipment not requiring additional stand or frame 

E0856 Cervical traction device, cervical collar with inflatable air bladder 

E0958 Manual wheelchair accessory, one-arm drive attachment 

E0959 Manual wheelchair accessory-adapter for Amputee 

E0960 Manual wheelchair accessory, shoulder harness/strap 

E0961 Manual wheelchair accessory wheel lock brake extension handle 

E0966 Manual wheelchair accessory, headrest extension 

E0967 Manual wheelchair accessory, hand rim with projections 

E0968 Commode seat, wheelchair 

E0969 Narrowing device wheelchair 

E0971 Manual wheelchair accessory anti-tipping device 

E0973 Manual wheelchair accessory, adjustable height, detachable armrest 

E0974 Manual wheelchair accessory anti-rollback device 

E0978 Manual wheelchair accessory positioning belt/safety belt/ pelvic strap 

E0980 Manual wheelchair accessory safety vest 

E0981 Manual wheelchair accessory Seat upholstery, replacement only 

E0982 Manual wheelchair accessory, back upholstery, replacement only 

E0983 

Manual wheelchair accessory power add on to convert manual 

wheelchair to motorized wheelchair, joystick control 

E0984 

Manual wheelchair accessory power add on to convert manual 

wheelchair to motorized wheelchair, Tiller control 

E0985 Wheelchair accessory, seat lift mechanism 

E0986 Manual wheelchair accessory, push activated power assist 

E0990 Manual wheelchair accessory, elevating leg rest 

E0992 Manual wheelchair accessory, elevating leg rest solid seat insert 

E0994 Arm rest 

E0995 Wheelchair accessory calf rest 

E1002 Wheelchair accessory Power seating system, tilt only 

E1003 

Wheelchair accessory Power seating system, recline only without 

shear 

E1004 

Wheelchair accessory Power seating system, recline only with 

mechanical shear 

E1005 

Wheelchair accessory Power seating system, recline only with power 

shear 

E1006 

Wheelchair accessory Power seating system, tilt and recline without 

shear 

E1007 

Wheelchair accessory Power seating system, tilt and recline with 

mechanical shear 
CMS-1590-P 268 

HCPCS 

Code Description 

E1008 

Wheelchair accessory Power seating system, tilt and recline with 

power shear 

E1010 

Wheelchair accessory, addition to power seating system, power leg 

elevation system, including leg rest pair 

E1014 Reclining back, addition to pediatric size wheelchair 

E1015 Shock absorber for manual wheelchair 

E1020 Residual limb support system for wheelchair 

E1028 

Wheelchair accessory, manual swing away, retractable or removable 

mounting hardware for joystick, other control interface or positioning 

accessory 

E1029 Wheelchair accessory, ventilator tray 

E1030 Wheelchair accessory, ventilator tray, gimbaled 

E1031 Rollabout chair, any and all types with castors 5" or greater 

E1035 

Multi-positional patient transfer system with integrated seat operated 

by care giver 

E1036 Patient transfer system 

E1037 Transport chair, pediatric size 

E1038 Transport chair, adult size up to 300lb 

E1039 Transport chair, adult size heavy duty >300lb 

E1161 Manual Adult size wheelchair includes tilt in space 

E1227 Special height arm for wheelchair 

E1228 Special back height for wheelchair 

E1232 

Wheelchair, pediatric size, tilt-in-space, folding, adjustable with 

seating system 

E1233 

Wheelchair, pediatric size, tilt-in-space, folding, adjustable without 

seating system 

E1234 

Wheelchair, pediatric size, tilt-in-space, folding, adjustable without 

seating system 

E1235 Wheelchair, pediatric size, rigid, adjustable, with seating system 

E1236 Wheelchair, pediatric size, folding, adjustable, with seating system 

E1237 Wheelchair, pediatric size, rigid, adjustable, without seating system 

E1238 

Wheelchair, pediatric size, folding, adjustable, without seating 

system 

E1296 Special sized wheelchair seat height 

E1297 Special sized wheelchair seat depth by upholstery 

E1298 Special sized wheelchair seat depth and/or width by construction 

E1310 Whirlpool non-portable 

E2502 

Speech Generating Devices prerecord messages between 8 and 20 

Minutes 

E2506 Speech Generating Devices prerecord messages over 40 minutes 

E2508 Speech Generating Devices message through spelling, manual type 

E2510 

Speech Generating Devices synthesized with multiple message 

methods 
CMS-1590-P 269 

HCPCS 

Code Description 

E2227 Rigid pediatric wheelchair adjustable 

K0001 Standard wheelchair 

K0002 Standard hemi (low seat) wheelchair 

K0003 Lightweight wheelchair 

K0004 High strength ltwt wheelchair 

K0005 Ultra Lightweight wheelchair 

K0006 Heavy duty wheelchair 

K0007 Extra heavy duty wheelchair 

K0009 Other manual wheelchair/base 

K0606 AED garment with electronic analysis 

K0730 Controlled dose inhalation drug delivery system 
CMS-1590-P 270 

c. Physician Payment 

We understand that there is a burden associated with the requirement placed on the 

physician to document that a face-to-face encounter has occurred between a PA, a NP or a CNS, 

and the beneficiary. Accordingly, we are proposing the introduction of a G-code, estimated at 

$15, to compensate a physician who documented that a PA, a NP, or a CNS practitioner has 

performed a face-to-face encounter for the list of specified covered items above. This G-code 

would become effective when this provision becomes effective. We believe that the existing 

Evaluation and Management (E&M) codes are sufficient for practitioners performing face-toface encounters. This new G-code would be specifically designed and mapped only for a 

physician who completes the documentation of the face-to-face encounter performed by a PA, a 

NP, or a CNS. Only a physician who does not bill an E&M code for the beneficiary in question 

would be eligible for this G-code. If multiple written orders for covered items of DME originate 

from one visit, the physician can receive the G-code payment only once for documenting that the 

face-to-face encounter has occurred. The G-code would be mapped so that only eligible DME 

items would be covered. Upon request, we will need to see documentation of the face-to-face 

encounter in order to verify the appropriateness of the G-code payment. 

D. Elimination of the Requirement for Termination of Non-random Prepayment Complex 

Medical Review (§421.500 through §421.505)

 Medical review is the process performed by Medicare contractors to ensure that billed 

items or services are covered and are reasonable and necessary as specified under section 

1862(a)(1)(A) of the Act. We enter into contractual agreements with contractors to perform 

medical review functions. On December 8, 2003, the Congress enacted the MMA. Section 934 

of the MMA amended section 1874A of the Act by adding a new subsection (h) – regarding 

random prepayment reviews and non-random prepayment complex medical reviews and 
CMS-1590-P 271 

requiring us to establish termination dates for non-random prepayment complex medical reviews. 

Although section 934 of the MMA set forth requirements for random prepayment review, our 

contractors do not perform random prepayment review. However, our contractors do perform 

non-random prepayment complex medical review. 

 On September 26, 2008, we published a final rule in the Federal Register (73 FR 55753) 

entitled, “Medicare Program; Termination of Non-Random Prepayment Complex Medical 

Review” that specified the criteria contractors would use for the termination of providers and 

suppliers from non-random prepayment complex medical review as required under the MMA. 

The final rule required contractors to terminate the non-random prepayment complex medical 

review of a provider or supplier no later than 1 year following the initiation of the complex 

medical review or when calculation of the error rate indicates the provider or supplier has 

reduced its initial error rate by 70 percent or more. (For more detailed information, see the 

September 26, 2008 final rule (73 FR 55753)). 

On March 23, 2010, the Congress enacted the Patient Protection and Affordable Care Act 

(Pub. L. 111-148) and the Health Care and Education Reconciliation Act of 2010 (HCERA) 

(Pub. L. 111-152) (together known as the Affordable Care Act). Section 1302 of the HCERA, 

repealed section 1874A(h) of the Act. 

 Section 1302 of the HCERA repealed section 1874A (h) of the Act, and therefore, 

removed the statutory basis for our regulation. Thus, we propose to remove the regulatory 

provisions in 42 CFR part 421, subpart F, that require contractors to terminate a provider or 

supplier from non-random prepayment complex medical review no later than 1 year following 

the initiation of the medical review or when the provider or supplier has reduced its initial error 

rate by 70 percent or more. As a result of this proposal, contractors would not be required to 

terminate non-random prepayment medical review by a prescribed time but would instead 
CMS-1590-P 272 

terminate each medical review when the provider or supplier has met all Medicare billing 

requirements as evidenced by an acceptable error rate as determined by the contractor. 

E. Ambulance Coverage-Physician Certification Statement

We propose to revise §410.40(d)(2) by incorporating nearly the same provision found at 

§410.40(d)(3)(v) to clarify that a physician certification statement (PCS) does not, in and of 

itself, demonstrate that a nonemergency, scheduled, repetitive ambulance service is medically 

necessary for Medicare coverage. The Medicare ambulance benefit at section 1861(s)(7) of the 

Act allows for “ambulance service where the use of other methods of transportation is 

contraindicated by the individual’s condition, but. . . only to the extent provided in regulations.” 

In other words, the definition of the benefit itself embodies the clinical medical necessity 

requirement that other forms of transportation must be contraindicated by a beneficiary’s 

condition. Section 410.40(d) interprets the medical necessity requirement. Notably, even aside 

from the requirements of section 1861(s)(7), section 1862(a)(1)(A) of the Act dictates that any 

service that is not medically necessary under the Act and regulations is not a covered benefit. 

Despite these statutory provisions and the language of the present regulation at section 

410.40(d)(2) that we believe already requires both medical necessity and a PCS, some courts 

have recently concluded that §410.40(d)(2) establishes that a sufficiently detailed and timely 

order from a beneficiary’s physician, to the exclusion of any other medical necessity 

requirements, conclusively demonstrates medical necessity with respect to nonemergency, 

scheduled, repetitive ambulance services. 

Absent explicit statutorily-based exceptions, we have consistently maintained that the 

Secretary is the final arbiter of whether a service is reasonable and necessary and qualifies for 

Medicare coverage. For example, in HCFA Ruling 93-1, we said “[i]t is HCFA’s ruling that no 

presumptive weight should be assigned to the treating physician’s medical opinion in 
CMS-1590-P 273 

determining the medical necessity of inpatient hospital or SNF services under section 1862(a)(1) 

of the Act. A physician’s opinion will be evaluated in the context of the evidence in the 

complete administrative record. Even though a physician’s certification is required for payment, 

coverage decisions are not made based solely on this certification; they are made based on 

objective medical information about the patient’s condition and the services received. This 

information is available from the claims form and, when necessary, the medical record which 

includes the physician’s certification.” 

Medical necessity is not just an integral requirement of Medicare’s ambulance benefit in 

particular, but as we mentioned, section 1862(a)(1)(A) of the Act dictates that services must be 

reasonable and necessary to qualify for any Medicare coverage. Numerous U.S. Circuit Courts 

of Appeal have held that PCSs or certificates of medical necessity do not, in and of themselves, 

conclusively demonstrate medical necessity. The same applies in the context of nonemergency, 

scheduled, repetitive ambulance services—the PCS is not, in and of itself, the sole determinant 

of medical necessity, and, as we discuss below, we believe the existing regulation at 

§410.40(d)(2) already demonstrates that. To erase any doubt, however, we propose a revision to 

§410.40(d)(2) to explicitly clarify this principle. 

Since being finalized in the February 27, 2002 Federal Register (67 FR 9100, 9132), 

§410.40(d)(2) has stated that “Medicare covers medically necessary nonemergency, scheduled, 

repetitive ambulance services if the ambulance provider or supplier, before furnishing the service 

to the beneficiary, obtains a written order from the beneficiary’s attending physician certifying 

that the medical necessity requirements of paragraph (d)(1) of this section are met.” (emphasis 

added). Although a physician certifies with respect to medical necessity, the Secretary is the 

final arbiter of whether a service is medically necessary for Medicare coverage. Indeed, the 

phrase “medically necessary” would have been surplus had we intended the PCS to be the sole 
CMS-1590-P 274 

determinant of medical necessity. Rather, as demonstrated by the fact that we did include that 

phrase, and by various other clarifying points, we made clear that a PCS, while necessary, does 

not on its own conclusively demonstrate the medical necessity of nonemergency, scheduled, 

repetitive ambulance services. 

The preamble to the February 27, 2002 final rule (Medicare Program; Fee Schedule for 

Payment of Ambulance Services and Revisions to the Physician Certification Requirements for 

Coverage of Nonemergency ambulance Services (67 FR 9100)) and the 1999 final rule with 

comment (FRC) (Medicare Program; Coverage of Ambulance Services and Vehicle and Staff 

Requirements (64 FR 3637)) support this interpretation. 

For example, in describing comments regarding medical necessity and physician 

certification in the 1999 FRC, we said: “[t]wo ambulance suppliers commented that physicians 

are unaware of the coverage requirements for ambulance services and that their decisions to 

request ambulance services may be based on ‘family preference or the inability to safely 

transport the beneficiary by other means rather than on the medical necessity requirement 

imposed by Medicare.’” We responded that section 1861(s)(7) of the Act allows coverage only 

under certain limited circumstances, and suggested that “[t]o facilitate awareness of the Medicare 

rules as they relate to the ambulance service benefit, ambulance suppliers may need to educate 

the physician (or the physician’s staff members) when making arrangements for the ambulance 

transportation of a beneficiary.” We continued that “[s]uppliers may wish to furnish an 

explanation of applicable medical necessity requirements, as well as requirements for physician 

certification, and to explain that the certification statement should indicate that the ambulance 

services being requested by the attending physician are medically necessary.” (76 FR 3637, 

3641) In light of our acknowledging a significant program vulnerability – that the physicians 

writing PCSs might not be fully cognizant of the Medicare ambulance benefit’s medical 
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necessity requirements – and encouraging suppliers themselves to help remedy that by educating 

physicians, it would have been irrational of us to (and we did not) abrogate the Secretary’s 

judgment and vest exclusively in the PCS the authority to demonstrate an ambulance transport’s 

medical necessity. We made a similar point in response to a separate comment: “It is always the 

responsibility of the ambulance supplier to furnish complete and accurate documentation to 

demonstrate that the ambulance service being furnished meets the medical necessity criteria.” 

(76 FR 3637, 3639). 

In the section of the February 27, 2002 final rule preamble describing the PCS 

requirements, we said: “[i]n all cases, the appropriate documentation must be kept on file and, 

upon request, presented to the carrier or intermediary. It is important to note that the presence of 

the signed physician certification statement does not necessarily demonstrate that the transport 

was medically necessary. The ambulance supplier must meet all coverage criteria for payment to 

be made.” (67 FR 9100, 9111). Although we incorporated that passage into the final rule only at 

§410.40(d)(3)(v), we intended, and we believe our intent is clear from the preamble narrative, 

that the principle apply equally to all nonemergency ambulance transports. 

The OIG report titled “Medicare Payments for Ambulance Transports” (OEI-05-02-

00590) (January 2006) also supports our position. Based on its analysis of a sample of calendar 

year 2002 claims, the OIG reported that “27 percent of ambulance transports to or from dialysis 

facilities did not meet Medicare’s coverage criteria.” The OIG added “the ongoing and repetitive 

nature of dialysis treatment makes transports to and from such treatment vulnerable to abuse. 

Although the condition of some patients warrants repetitive, scheduled ambulance transports for 

dialysis treatment, many dialysis transports do not meet coverage criteria.” The OIG 

recommended that we instruct our contractors to implement prepayment edits with respect to 

dialysis transports and have them request wide-ranging documents when conducting 
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postpayment medical review. The fact that we agreed with the OIG’s recommendations 

demonstrated our belief that the PCS was not the sole determinant of medical necessity. 

Likewise, the fact that the OIG mentioned our ambulance coverage regulations, including the 

PCS requirement, but did not recommend altering or clarifying the regulations with respect to 

medical necessity demonstrated that we were of like mind; that, while a physician certifies with 

respect to medical necessity, the Secretary is the final arbiter of whether a service is medically 

necessary. 

Accordingly, we propose to revise §410.40(d)(2) to add nearly the same provision 

presently found at §410.40(d)(3)(v), except without reference to a “signed return receipt” that 

does not pertain to nonemergency, scheduled, repetitive ambulance services. We propose to 

accomplish this by redesignating the current language as §410.40(d)(2)(i), and adding the 

clarifying language to a new §410.40(d)(2)(ii). The proposed §410.40(d)(2)(ii) clarifies that a 

signed physician certification statement does not, in and of itself, demonstrate that an ambulance 

transport was reasonable and necessary. Rather, for all ambulance services, providers and 

suppliers must retain on file all appropriate documentation and present such documentation upon 

request to a Medicare contractor. A CMS contractor may use such documentation to assess, 

among other things, whether the service satisfied Medicare’s medical necessity, eligibility, 

coverage, benefit category, or any other criteria necessary for Medicare payment to be made. 

For example, the patient’s condition must be such that other means of transportation would be 

contraindicated, and the expenses incurred must be reasonable and necessary for the diagnosis or 

treatment of illness or injury. 

We also propose to fix the typographical error “fro,” which should be “from” in the 

existing § 410.40(c)(3)(ii). 
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F. Physician Compare Website

1. Background and Statutory Authority 

 Section 10331(a)(1) of the Affordable Care Act requires that, by no later than 

January 1, 2011, we develop a Physician Compare Internet website with information on 

physicians enrolled in the Medicare program under section 1866(j) of the Act, as well as 

information on other eligible professionals who participate in the Physician Quality Reporting 

System under section 1848 of the Act. 

 We launched the first phase of the Physician Compare Internet website 

(http://www.medicare.gov/find-a-doctor/provider-search.aspx) on December 30, 2010. This 

initial phase included the posting of the names of eligible professionals that satisfactorily 

submitted quality data for the 2009 Physician Quality Reporting System, consistent with section 

1848(m)(5)(G) of the Act. Since the initial launch of the website, we have continued to build 

and improve Physician Compare. Currently users can search by selecting a location and 

specialty for physicians or other healthcare professionals. Search results provide basic 

information about approved Medicare providers, such as primary and secondary specialties, 

practice locations, group practice affiliations, hospital affiliations, Medicare Assignment, 

education, languages spoken, and gender. As required by section 1848(m)(5)(G) of the Act, we 

have added the names of those eligible professionals who are successful electronic prescribers 

under the Medicare Electronic Prescribing (eRx) Incentive Program. As such, physician and 

other healthcare professional profile pages indicate if professionals satisfactorily participated in 

the Physician Quality Reporting System and/or are successful electronic prescribers under the 

eRx Incentive Program based on the most recent data available for these two quality initiatives. 

2. Public Reporting of Physician Performance 

 Section 10331(a)(2) of the Affordable Care Act also requires that, no later than 
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January 1, 2013, and for reporting periods that begin no earlier than January 1, 2012, we 

implement a plan for making publicly available through Physician Compare, information on 

physician performance that provides comparable quality and patient experience measures. This 

plan is outlined below. 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. 

● 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. 

● 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 
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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 in selecting quality measures for Physician Compare, which we seek to 

accomplish through rulemaking and focus groups. 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 deems 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 Medicare Improvements for Patients and 

Providers Act of 2008. 

 We are required, under section 10331(f) of the Affordable Care Act, 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 to make informed decisions about their 
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health care, while encouraging clinicians to improve on the quality of care they provide to their 

patients. In accordance with section 10331 of the Affordable Care Act, we intend to utilize the 

Physician Compare website to publicly report physician performance results. 

 In implementing our plan to publicly report physician performance, we will use data 

reported under the existing Physician Quality Reporting System as an initial step for making 

physician “measure performance” information public on Physician Compare. By “measure 

performance” in relation to the Physician Quality Reporting System, we mean the percent of 

times that a particular clinical quality action was reported as being performed, or a particular 

outcome was attained, for the applicable persons to whom a measure applies as described in the 

denominator for the measure. For measures requiring risk adjustment, “measure performance” 

refers to the risk adjusted percentage of times a particular outcome was attained. 

 We previously finalized a decision to make public on Physician Compare the 

performance rates of the quality measures that group practices submit under the 2012 Physician 

Quality Reporting System group practice reporting option (GPRO) (76 FR 73417). Therefore, 

we anticipate, no earlier than 2013, posting performance information collected through the 

GPRO web interface for group practices participating in the Physician Quality Reporting System 

GPRO CY 2012 on Physician Compare. Specifically, we will make public performance 

information for measures included in the 2012 Physician Quality Reporting System that meet the 

minimum sample size, and that prove to be statistically valid and reliable. As we previously 

established, 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 for that 

measure will be suppressed and not publicly reported. We previously established a minimum 

threshold of 25 patients for reporting performance information on the Physician Compare 

website (76 FR 73418). Although we considered keeping the threshold for reporting 
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performance data on Physician Compare at 25 patients, we propose to change the minimum 

patient sample size, from 25 patients to 20 patients, beginning with data collected for services 

furnished in 2013, to align with the proposed minimum patient reporting thresholds for Physician 

Quality Reporting System measures group reporting for the 2013 and 2014 incentives, and the 

proposed reliability thresholds for the physician value-based payment modifier. We invite 

comment on the proposed new minimum patient sample size for Physician Compare, including 

whether or not we should retain the existing threshold of 25 patients. 

Furthermore, in the Shared Savings Program final rule (76 FR 67948) as codified at 

§425.308, we finalized ACO public reporting provisions in the interest of promoting greater 

transparency regarding the ACOs participating in the program. We finalized requirements for 

ACOs to publicly report certain data as well as data that we would publicly report. Because 

ACO providers/suppliers that are eligible professionals are considered to be group practices for 

purposes of qualifying for a Physician Quality Reporting System incentive under the Shared 

Savings Program, we indicated that performance on quality measures reported by ACOs at the 

ACO TIN level, on behalf of their ACO providers/suppliers who are eligible professionals, using 

the GPRO web interface would be reported on Physician Compare in the same way as for the 

groups that report under the Physician Quality Reporting System. 

In April 2012, we added functionality to Physician Compare allowing users to search for 

group practices in preparation for the addition of 2012 Physician Quality Reporting System 

GPRO data. A full website redesign is slated for early 2013 to further prepare the site for the 

introduction of quality data. With each enhancement, we work to improve the usability and 

functionality of the site, providing consumers with more tools to help them make informed 

healthcare decisions. 

In CY 2012, we intend to enhance the accuracy of “administrative” information displayed 
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on the eligible professional’s profile page, and to add additional data. By “administrative” data, 

we are referring to information about eligible professionals that is pulled from the Provider 

Enrollment, Chain, and Ownership System (PECOS) and other readily available external data 

sources. Specifically, we intend to add whether a physician/other health care professional is 

accepting new Medicare patients, board certification information, and to improve the foreign 

language and hospital affiliation data. We also intend to include the names of those eligible 

professionals who participated in the Medicare EHR Incentive Program and the names of those 

eligible professionals who satisfactorily participated under the Physician Quality Reporting 

System GPRO. We will continue to update the names of those eligible professionals and group 

practices who satisfactorily participated under the Physician Quality Reporting System, and 

those who are successful electronic prescribers under the eRx Incentive Program based on the 

most recent program year data available. 

In support of the HHS-wide Million Hearts Initiative, we propose to post the names of the 

eligible professionals who report the Physician Quality Reporting System Cardiovascular 

Prevention measures group. This is consistent with the requirements under section 10331 of the 

Affordable Care Act to provide information about physicians and other eligible professionals 

who participate in the Physician Quality Reporting System. 

3. Future Development of Physician Compare 

Consistent with Affordable Care Act requirements, we intend to phase in an expansion of 

Physician Compare over the next several years by incorporating quality measures from a variety 

of sources, if technically feasible. For our next phase, we propose to make public on Physician 

Compare, performance rates on the quality measures that group practices submit through the 

GPRO web interface under the 2013 Physician Quality Reporting System GPRO and the 

Medicare Shared Savings Program. We anticipate that the 2013 Physician Quality Reporting 
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System GPRO web interface measures data would be posted no sooner than 2014. This data 

would include measure performance rates for measures included in the 2013 Physician Quality 

Reporting System GPRO web interface that meet the proposed minimum sample size of 20 

patients, and that prove to be statistically valid and reliable. 

When technically feasible, but no earlier than 2014, we propose to publicly report 

composite measures that reflect group performance across several related measures. As an initial 

step we intend to develop disease module level composite scores for Physician Quality Reporting 

System GPRO measures. Under the Medicare Shared Savings Program, ACOs are required to 

report on composite measures for Diabetes Mellitus (DM) and Coronary Artery Disease (CAD) 

(76 FR 67891). Accordingly, in an effort to align the PQRS GPRO measures with the GPRO 

measures under the Shared Savings Program, we have proposed in Table 35 of this proposed rule 

to add composite measures for DM and CAD into the Physician Quality Reporting System 

starting in 2013. We will also consider future development of composites for the remaining 

disease level modules within the GPRO web interface. As more data are added to Physician 

Compare over time, we will consider adding additional disease level composites across measure 

types as technically feasible and statistically valid. 

Consistent with the requirement under section 10331(a)(2) under the Affordable Care Act 

to implement a plan to make publically available comparable information on patient experience 

of care measures, we propose to add patient experience survey-based measures such as, but not 

limited to, the Clinician and Group Consumer Assessment of Healthcare Providers and Systems 

(CG-CAHPS). As discussed in section G.6.c. of this proposed rule, we propose to collect the 

following patient experience of care measures for group practices participating in the Physician 

Quality Reporting System GPRO; 

• CAHPS: Getting Timely Care, Appointments, and Information 
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• CAHPS: How Well Your Doctors Communicate 

• CAHPS: Patients’ Rating of Doctor 

• CAHPS: Access to Specialists 

• CAHPS: Health Promotion and Education 

These measures capture patients’ experiences with clinicians and their staff, and patients’ 

perception of care. We propose, no earlier than 2014, to publicly report 2013 patient experience 

data for all group practices participating in the 2013 Physician Quality Reporting System GPRO, 

not limited to those groups participating via the GPRO web interface, on Physician Compare. At 

least for 2013, we intend to administer and collect patient experience survey data on a sample of 

the group practices’ beneficiaries. As we intend to administer and collect the data for these 

surveys, we do not anticipate any notable burden on the groups. 

For ACOs participating in the Shared Savings Program, consistent with the Physician 

Quality Reporting System proposal to publicly report patient experience measures on Physician 

Compare starting in 2013, we propose to publicly report patient experience data in addition to the 

measure data reported through the GPRO web interface. Specifically, the patient experience 

measures that would be reported for ACOs include the CAHPS measures in the 

Patient/Caregiver Experience domain finalized in the Shared Savings Program final rule (76 FR 

67889): 

• CAHPS: Getting Timely Care, Appointments, and Information 

• CAHPS: How Well Your Doctors Communicate 

• CAHPS: Patients’ Rating of Doctor 

• CAHPS: Access to Specialists 

• CAHPS: Health Promotion and Education 

• CAHPS: Shared Decision Making 
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For patient experience data reported under either the Physician Quality Reporting System 

GPRO or the Medicare Shared Savings Program, we also considered an alternative option of 

providing confidential feedback to group practices and ACOs using 2013 patient experience data 

before publicly reporting patient experience data on Physician Compare. In lieu of publicly 

reporting the patient experience data relating to 2013 Physician Quality Reporting System GPRO 

and ACOs participating in the Shared Savings Program, we considered using the 2013 results as 

a baseline to be shared confidentially with the group practices and ACOs, during which time the 

group practices and ACOs would have the opportunity to review their data, and implement 

changes to improve patient experience scores. Under this alternative option, program year 2014 

patient experience data would be the first to be publicly reported on Physician Compare, and we 

would publicly report 2014 patient experience data for ACOs and group practices participating in 

the 2014 Physician Quality Reporting System GPRO on Physician Compare no earlier than 

2015. We invite public comment on our proposal to begin publicly reporting patient experience 

data for program year 2013, and also the alternative option of delaying public reporting of patient 

experience of care data on Physician Compare until program year 2014 in order to give group 

practices and ACOs the opportunity to make changes to the processes used in their practices 

based on the review of their data from program year 2013. 

As we continue to improve administrative and provider level data, we propose posting the 

names of those physicians who earned a Physician Quality Reporting System Maintenance of 

Certification Program incentive as data becomes available, but no sooner than 2014. 

Additionally, we are considering allowing measures that have been developed and collected by 

approved and vetted specialty societies to be reported on Physician Compare, as deemed 

appropriate, and as they are found to be scientifically sound and statistically valid. We propose 

including additional claims-based process, outcome and resource use measures on Physician 
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Compare, and intend to align measure selection for Physician Compare with measures selected 

for the Value Based Modifier (section III.K). 

As an initial step, we propose to include group level ambulatory care sensitive condition 

admission measures of potentially preventable hospitalizations developed by the HHS Agency 

for Healthcare Research and Quality (AHRQ) that meet the proposed minimum sample size of 

20 patients, and that prove to be statistically valid and reliable (measure details are available at 

http://www.qualitymeasures.ahrq.gov/content.aspx?id=27275). We propose reporting these 

measures on Physician Compare no earlier than 2015 for those group practices comprised of 2 - 

99 eligible professionals participating in the proposed 2014 physician Quality Reporting System 

GPRO, and for ACOs. As our next step, we propose to publicly report performance rates on 

quality measures included in the 2015 Physician Quality Reporting System and value-based 

payment modifier for individual eligible professionals. Further details on what measures would 

be included in the 2015 reporting period will be addressed in future rule making. Public reporting 

of 2015 PQRS and administrative claims-based quality measures for individuals would occur no 

earlier than 2016. For all measures publicly reported on the Physician Compare website, we 

propose to post a standard of care, such as those endorsed by the National Quality Forum. Such 

information will serve as a standard for consumers to measure individual provider, and group 

level data. 

We are committed to making Physician Compare a constructive tool for Medicare 

beneficiaries, successfully meeting the Affordable Care Act mandate, and in doing so, providing 

consumers with information needed to make informed healthcare decisions. CMS has developed 

a plan, and started to implement a phased approach to adding quality data to Physician Compare. 

We believe a staged approach to public reporting of physician information allows for the use of 

information currently available while we develop the infrastructure necessary to support the 
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collection of additional types of measures and public reporting of individual physicians’ quality 

measure performance results. Implementation of subsequent phases of the plan will need to be 

developed and addressed in future notice and comment rulemaking, as needed. 

We invite comments regarding our proposals to: (1) reduce the minimum reporting 

threshold from 25 patients to 20 patients for reporting on Physician Compare; (2) post the names 

of the eligible professionals who report the Physician Quality Reporting System Cardiovascular 

Prevention measures group for purposes of recognition and in support of the Million Hearts 

Initiative; (3) develop composite measures at the disease module level, initially with CY 2013 

GPRO data, and incorporating additional measures; (4) to publicly report 2013 patient 

experience data for group practices participating in the 2013 Physician Quality Reporting System 

GPRO, or who are part of an ACO under the Medicare Shared Savings Program, on the 

Physician Compare website no earlier than 2014; (5) the alternative option of providing 

confidential feedback to group practices and ACOs on 2013 patient experience data to allow 

them to make necessary changes to their processes prior to publicly reporting of 2014 patient 

experience data on Physician Compare; (6) report names of participants who earn a 2013 

Physician Quality Reporting System Maintenance of Certification Program Incentive no earlier 

than 2014; (7) allow measures that have been developed and collected by specialty societies to 

be reported on the Physician Compare website as deemed appropriate; (8) to report 2014 group 

level ambulatory care sensitive condition measures of potentially preventable hospitalizations 

developed by the AHRQ no earlier than 2015 for groups participating in the 2014 Physician 

Quality Reporting System and ACOs, (measure details are available at 

http://www.qualitymeasures.ahrq.gov/content.aspx?id=27275); (9) publicly report performance 

on 2015 Physician Quality Reporting System and value-based payment modifier quality 

measures for individuals. Public reporting of 2015 Physician Quality Reporting System and 
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claims derived quality measures for individuals would occur no earlier than 2016; and (10) post a 

standard of care for measures posted on Physician Compare. For the above proposals, we note 

that we would only post data on Physician Compare if it is technically feasible; the data is 

available; the system is set up/adjusted to post information and the data is useful, sufficiently 

reliable, and accurate. 
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G. Physician Payment, Efficiency, and Quality Improvements – Physician Quality Reporting 

System

 There are several healthcare quality improvement programs that affect physician 

payments under the Medicare PFS. The National Quality Strategy establishes three aims for 

quality improvement across the nation: better health, better healthcare, and lower costs. This 

strategy, the first of its kind, outlines a national vision for quality improvement and creates an 

opportunity for programs to align quality measurement and incentives across the continuum of 

care. CMS believes that this alignment is especially critical for programs involving physicians. 

The proposals that follow facilitate the alignment of programs, reporting systems, and quality 

measures to make this vision a reality. We believe that alignment of CMS quality improvement 

programs will decrease the burden of participation on physicians and allow them to spend more 

time and resources caring for beneficiaries. Furthermore, as the leaders of care teams and the 

healthcare systems, physicians and other clinicians serve beneficiaries both as frontline and 

system-wide change agents to improve quality. CMS believes, however, that in order to improve 

quality, physicians must first engage in quality measurement and reporting. It is CMS's intent 

that the following proposals will improve alignment of physician-focused quality improvement 

programs, decrease the burden of successful participation on physicians, increase engagement of 

physicians in quality improvement, and ultimately lead to higher quality care for beneficiaries. 

This section contains our proposals related to the Physician Quality Reporting System 

(PQRS). The PQRS, as set forth in section 1848(a), (k), and (m) of the Act, is a quality reporting 

program that provides incentive payments and payment adjustments to eligible professionals 

who satisfactorily report data on quality measures for covered professional services furnished 

during a specified reporting period. We note that, in developing these proposals, it was our goal 

to align program requirements between these quality reporting programs, such as the eRx 
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Incentive Program, EHR Incentive Program, Medicare Shared Savings Program, and value-based 

payment modifier, wherever possible. We believe that alignment of these quality reporting 

programs will lead to greater overall participation in these programs, as well as minimize the 

reporting burden on eligible professionals. 

For example, we have aligned the definition of group practice under the eRx Incentive 

Program with PQRS’ definition of group practice. Our proposals with respect to reporting as a 

group practice for the eRx Incentive Program are intended to conform to our proposals for 

reporting as a group practice for PQRS. 

With respect to integration with the EHR Incentive Program, section 1848(m)(7) of the 

Act requires us to develop a plan to integrate reporting on quality measures under the PQRS with 

reporting requirements under the EHR Incentive Program. We began integrating requirements 

for these two programs in 2012 with the alignment of reporting requirements via the Physician 

Quality Reporting System-Medicare EHR Incentive Pilot (76 FR 73422) and the alignment of 

reportable EHR measures (76 FR 73364). Our proposals in this section are intended to move the 

PQRS and EHR Incentive Program towards greater alignment, benefiting those eligible 

professionals who wish to participate in both programs. The vision is to report once for multiple 

programs on a set of measures aligned across programs and with the National Quality Strategy. 

With respect to integration with the value-based payment modifier, we note that we 

began our efforts to integrate our program requirements with the value-based payment modifier 

in the CY 2012 Medicare PFS final rule, when CY 2013 was established as the reporting period 

for the 2015 PQRS payment adjustment (76 FR 73391) and the initial performance period for the 

application of the value modifier (76 FR 73435). Our proposals in this section, particularly as 

they relate to the proposed requirements for satisfactory reporting for the PQRS payment 

adjustments, are intended to align with the proposals for the application of the value modifier. 
CMS-1590-P 291 

The regulation governing the PQRS is located at §414.90. The program requirements for 

years 2007-2012 of the PQRS that were previously established, as well as information on the 

PQRS, including related laws and established requirements, are available at 

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/index.html. Please also note that in this proposed rule, we are proposing to 

make technical changes to §414.90 to aid in the readability of the regulation. 

1. Methods of Participation 

There are two ways an eligible professional can participate in the PQRS: (1) as in 

individual or (2) as part of a group practice participating in the PQRS group practice reporting 

option (GPRO). 

a. Participation as an Individual Eligible Professional 

(1) Participation for the 2013 and 2014 Incentives 

As defined at §414.90(b) the term ‘‘eligible professional’’ means any of the following: 

(1) a physician; (2) a practitioner described in section 1842(b)(18)(C) of the Act; (3) a physical 

or occupational therapist or a qualified speech-language pathologist; or (4) a qualified 

audiologist. For more information on which professionals are eligible to participate in the 

Physician Quality Reporting System, we refer readers to the ‘‘List of Eligible Professionals’’ 

download located in the ‘‘How to Get Started” section of the PQRS CMS Website at 

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/How_To_Get_Started.html. There is no requirement to self-nominate to 

participate in PQRS as an individual eligible professional for the incentive or to use the claims, 

registry, or EHR reporting mechanisms. 

(2) Proposed Requirement for Eligible Professionals and Group Practices Electing to Use the 

Administrative Claims-based Reporting Mechanism for the 2015 and 2016 Payment Adjustments 
CMS-1590-P 292 

 Unlike using the traditional PQRS reporting mechanisms (claims, registry, EHRs) to 

satisfy the reporting requirements for the 2015 and 2016 payment adjustments, we propose that 

eligible professionals and group practices wishing to use the administrative claims reporting 

mechanism, which is discussed in section K, and available for the 2015 and/or 2016 payment 

adjustments, must elect to use the administrative claims reporting mechanism (please note that 

since the same proposed requirements would apply to both individual eligible professionals and 

group practices, we address both in this discussion). We believe this election requirement is 

necessary because CMS must be notified that CMS must analyze and calculate data from an 

eligible professional or group practice’s claims. This election requirement is not necessary for 

eligible professionals and group practices using traditional PQRS reporting mechanisms because, 

for these traditional reporting mechanisms, CMS is not involved with analyzing claims data to 

determine whether a clinical quality action related to a quality measure was performed. 

 For eligible professionals, we propose that this election process would consist of a 

registration statement that includes: the eligible professional’s name and practice name, the 

eligible professional’s TIN and NPI for analytical purposes, and the eligible professional’s 

contact information. For group practices, we propose that this election process would also 

consist of a registration statement that includes: the group practice’s business name and contact 

information, the group practice’s TIN, and contact information of the group practice’s contact(s) 

who will be contacted for program, clinical, and/or technical purposes. With respect to the 

method of submitting this registration statement, we propose the following options: 

- If technically feasible, submission of this statement via the web and 

- If technically feasible, submission of an eligible professional’s or group practice’s intent to 

register to use the administrative claims-based reporting mechanism by placing a G-code on 

at least 1 Medicare Part B claim. 
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In the event the two proposed options are not technically feasible, we also considered allowing 

for submission of the registration statement by submitting a mailed letter to CMS at Centers for 

Medicare & Medicaid Services, Office of Clinical Standards and Quality, Quality Measurement 

and Health Assessment Group, 7500 Security Boulevard, Mail Stop S3-02-01, Baltimore, MD 

21244-1850a. However, we note that using this mailing option would be a more burdensome 

and time-intensive process for CMS. We invite public comment on this considered option. 

 The eligible professional would be required to complete this election process by January 

31 of the applicable payment adjustment reporting period (for example, by January 31, 2015 for 

the 2015 payment adjustment). However, we note that we propose that we may extend this 

deadline based on the submission method that is finalized. For example, because processing 

mailed letters would take the longest to process (out of the 3 methods), we anticipate that if we 

were to include the option of mailed letters the deadline for submitting a mailed registration 

letter would be January 31 of the applicable payment adjustment reporting period. Since it 

would be more efficient to process registration statements received via the web or via a G-code 

on a claim, we anticipate that we would be able to extend the registration deadline to as late as 

December 31 of the applicable payment adjustment reporting period. Once an eligible 

professional makes an election to participate in PQRS using the administrative claims-based 

reporting mechanism for the PQRS payment adjustments, the eligible professional would be 

assessed under the administrative claims-based reporting mechanism. 

 For group practices participating in the GPRO, we propose that these group practices 

would use the 2 methods described above (mailed letter, web, or G-code submission) and have 

the same deadline as eligible professionals wishing to elect to use the administrative claimsbased reporting mechanism for an applicable payment adjustment. In the alternative, we propose 

that a group practice participating in the GPRO would be required to elect to use the 
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administrative claims-based reporting mechanism in its self-nomination statement. We are 

proposing to provide less time for group practices to elect to use the administrative claims-based 

reporting mechanism because it is necessary for CMS to receive this information in the 

beginning of the applicable reporting period to indicate to CMS how these group practices 

should be analyzed throughout the reporting period. This early notification is especially 

important for large group practices, which may have hundreds or thousands of eligible 

professionals to track as a group practice. Therefore, we feel it is appropriate to request that a 

group practice elect to use the administrative claims-based reporting mechanism when the group 

practice self-nominates. 

 We further propose that an eligible professional or group practice would be required to 

make this election for each payment adjustment year the eligible professional or group practice 

seeks to be analyzed under this mechanism. For example, if the eligible professional seeks to 

report under the administrative claims mechanism for the 2015 and 2016 payment adjustments, 

the eligible professional would be required to make this election by the applicable deadline, for 

the 2015 payment adjustment and again by the applicable deadline, for the 2016 payment 

adjustment. We invite public comment on the proposed election requirement for eligible 

professionals and group practices electing to participate in the 2015 and 2016 payment 

adjustments using the administrative claims-based reporting mechanism. 

b. Participation as a Group Practice in the GPRO 

(1) Proposed Definition of Group Practice 

We propose to modify §414.90(b) to define group practice as “a single Tax Identification 

Number (TIN) with 2 or more eligible professionals, as identified by their individual National 

Provider (NPI), who have reassigned their Medicare billing rights to the TIN.” We are 

proposing to change the number of eligible professionals comprising a PQRS group practice 
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from 25 or more to 2 or more to allow all groups of smaller sizes to participate in the GPRO. We 

believe that expanding the scope of group practices eligible to participate under the program will 

lead to greater program participation. To participate in the GPRO, a group practice would be 

required to meet this proposed definition at all times during the reporting period for the program 

year in which the group practice is selected to participate in the GPRO. We invite public 

comment on the proposed definition of group practice. 

(2) Proposed Election Requirement for Group Practices Selected to Participate in the GPRO 

 We established the process for group practices to be selected to participate in the GPRO 

in the CY 2012 PFS final rule with comment period (76 FR 73316). However, this section 

contains additional processes with respect to a group practice’s self-nomination statement that 

we are proposing for group practices selected to participate in the GPRO for 2013 and beyond. 

With respect to the requirement that group practices wishing to participate in the GPRO submit a 

self-nomination statement (76 FR 73316), for 2012, we accepted these self-nomination 

statements via a letter accompanied by an electronic file submitted in a format specified by CMS 

because it was not operationally feasible to receive self-nomination statements via the web at that 

time. In the CY 2012 Medicare PFS final rule with comment period, we noted that we 

anticipated that CMS would have the ability to collect self-nomination statements via the web for 

the 2013 Physician Quality Reporting System. We are therefore proposing that, for 2013 and 

beyond, a group practice must submit its self-nomination statement via the web. 

 We note that this web-based functionality is still being developed by CMS. Therefore, in 

the event this web-based functionality would not be available in time to accept self-nomination 

statements for the 2013 Physician Quality Reporting System, we propose that, in lieu of 

submitting self-nomination statements via the web, a group practice would be required to submit 

its self-nomination statement via a letter accompanied by an electronic file submitted in a format 
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specified by CMS (such as a Microsoft excel file). We propose that this self-nomination 

statement would be mailed to the following address: Centers for Medicare & Medicaid Services, 

Office of Clinical Standards and Quality, Quality Measurement and Health Assessment Group, 

7500 Security Boulevard, Mail Stop S3-02-01, Baltimore, MD 21244-1850. If mailing the selfnomination statement, we would require that this self-nomination statement be received by no 

later than 5 PM Eastern Standard Time on January 31 of the year in which the group practice 

wishes to participate in the GPRO. 

 In the CY 2012 Medicare PFS final rule with comment period, we also established what 

information is required to be included in a group practice’s self-nomination statement (76 FR 

73316). In previous years, the group practice only had one reporting mechanism available on 

which to report data on PQRS quality measures: the GPRO web-interface. However, beginning 

2013, we are proposing to allow group practices to report data on quality measures using the 

claims, registry, and EHR-based reporting mechanisms for the PQRS incentive and payment 

adjustment. Additionally, we are proposing to allow group practices to use the proposed 

administrative claims reporting option. We propose that a group practice wishing to participate 

in the GPRO for a program year would be required to indicate the reporting mechanism the 

group practice intends to use for the applicable reporting period in its self-nomination statement. 

Furthermore, once a group practice is selected to participate in the GPRO and indicates which 

reporting mechanism the group practice would use, we propose that the group practice would not 

be allowed to change its selection. Therefore, under this proposal, the reporting mechanism the 

group practice indicates it will use in its self-nomination statement for the applicable reporting 

period would be the only reporting mechanism under which CMS will analyze the group practice 

to determine whether the group practice has met the criteria for satisfactory reporting for the 

PQRS incentive and/or payment adjustment. We acknowledge that this proposal would depart 
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from the way we analyze an individual eligible professional, as CMS analyzes an individual 

eligible professional (who is permitted to use multiple reporting mechanisms during a reporting 

period) under every reporting method the eligible professional uses. Unfortunately, due to the 

complexity of analyzing group practices under the GPRO, such as having to associate multiple 

NPIs under a single TIN, it is not technically feasible for us to allow group practices using the 

GPRO to use multiple reporting mechanisms or switch reporting mechanisms during the 

reporting period. We invite public comment on the proposed election requirement and the 

proposed restriction noted above for group practices under the GPRO for 2013 and beyond. 

 (3) Proposed GPRO Selection Process 

 Group practices must be selected by CMS to participate in the PQRS GPRO for a 

program year. Please note that if a group practice is selected to participate in the PQRS as a 

GPRO, the eligible professionals in the selected group practice cannot participate in the PQRS 

individually. When selecting group practices to participate in the GPRO, CMS bases its decision 

on the information the group practice provides in its self-nomination statement. We believe that 

changes in a group practice’s size or TIN constitute such a significant change in the group 

practice’s composition that it would cause CMS to reconsider its decision to allow the group 

practice to participate in the GPRO for the applicable program year. Specifically, we understand 

that a group practice’s size may vary throughout the program year. For example, we understand 

that eligible professionals enter into and leave group practices throughout the year. Similarly, we 

understand that group practices may undergo business reorganizations during the program year. 

We note that size fluctuations may affect the criteria under which a group practice would use to 

report after being selected to participate in the GPRO. As indicated in section III.G.4., we are 

proposing that groups of varying sizes be subject to different criteria for satisfactory reporting for 

the 2013 and 2014 incentives, as well as for the payment adjustments. Therefore, we propose 
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that, for analysis purposes, the size of the group practice must be established at the time the 

group practice is selected to participate in the GPRO. We invite public comment on this 

proposal. 

We also understand that, for various reasons, a group practice may change TINs within a 

program year. For example, a group practice may undergo a mid-year reorganization that leads 

to the group practice changing its TIN mid-year. We propose that, if a group practice changes its 

TIN after the group practice is selected to participate in the GPRO, the group practice cannot 

continue participate in PQRS as a GPRO. We consider the changing of a group practice’s TIN a 

significant change to the makeup of the group practice, as the group practice is evaluated under 

the TIN the group practice provided to CMS at the time the group is selected to participate in the 

GPRO for the applicable year. Therefore, we view a group practice that changes its TIN as an 

entirely new practice, associated with a new TIN. We understand that this proposal may pose a 

disadvantage for those group practices who find it beneficial to report PQRS quality measures 

using the GPRO. However, we note that eligible professionals in a group practice that has 

changed its TIN within a year may still participate as individuals. We invite public comment on 

this proposal. 

We understand that a group practice may decide not to participate in PQRS using the 

GPRO after being selected. Therefore, we propose that group practices be provided with an 

opportunity to opt out of participation in the GPRO after selection. We note that it is necessary 

for a group practice to indicate to CMS the group practices’ intent not to use the GPRO because, 

once a group practice is selected to participate in the GPRO for the applicable reporting period, 

CMS will not separately assess the NPIs associated with the group practice’s TIN to see if they 

meet the criteria for satisfactory reporting for individual eligible professionals. Therefore, CMS 

must be notified of the group practice’s decision not to participate in the GPRO so the eligible 
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professionals within the group practice could be assessed at the individual TIN/NPI level. We 

propose that group practices have until April 1 of the year of the applicable reporting period (for 

example, by April 1, 2013 for reporting periods occurring in 2013) to opt out of participating in 

the GPRO. We invite public comment on the proposed selection process for group practices 

wishing to participate in the GPRO. 

(4) Proposed Requirement for Group Practices Electing to Use the Administrative Claims-based 

Reporting Mechanism for 2015 and 2016 Payment Adjustments 

 We propose an election requirement for group practices that elect to participate in the 

PQRS for the 2015 and 2016 payment adjustment using administrative claims-based reporting 

mechanism, which is discussed in full in section III.G.5. (which also addresses election 

requirements for eligible professionals). We seek comment on our proposal on election 

requirements for group practices that intend to report using the proposed administrative claims 

reporting option for the 2015 and 2016 payment adjustment. 

2. Proposed Reporting Periods for the PQRS Payment Adjustments for 2016 and Beyond 

For the PQRS incentives, we previously established 12 and 6-month reporting periods for 

satisfactorily reporting PQRS quality measures at §414.90(f)(1). Under section 

1848(a)(8)(C)(iii) of the Act, we are authorized to specify the quality reporting period (reporting 

period) with respect to a payment adjustment year. We propose to modify the regulation to 

establish the reporting periods for the PQRS payment adjustments for 2015 and beyond. 

For the 2015 payment adjustment, in the CY 2012 Medicare PFS final rule, we 

established CY 2013 (that is, January 1, 2013 through December 31, 2013) as the reporting 

period for the 2015 payment adjustment (76 FR 73392). We established a 12-month reporting 

period occurring 2 years prior to the application of the payment adjustments for group practices 

and for individual eligible professionals to allow time to perform all reporting analysis prior to 
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applying payment adjustments on eligible professionals’ Medicare Part B PFS claims. However, 

we note that we might specify additional reporting periods for the 2015 payment adjustment. To 

coincide with the 6-month reporting period associated with the 2013 incentive for the reporting 

of measures groups via registry, we propose to modify the regulation at newly designated 

§414.90(h) to add a 6-month reporting period occurring July 1, 2013—December 31, 2013, for 

the 2015 payment adjustment for the reporting of measures groups via registry. 

For 2016 payment adjustments, to coincide with the reporting periods for the 2014 

incentive, we propose to modify the regulation at newly designated §414.90(h) to specify a 12-

month (January 1, 2014 – December 31, 2014) and, for individual eligible professionals 

reporting measures groups via registry only, a 6-month (July 1, 2014—December 31, 2014) 

reporting periods for the 2016 payment adjustments. 

We believe that data on quality measures collected based on 12-months provides a more 

accurate assessment of actions performed in a clinical setting than data collected based on a 6-

month reporting period. Therefore, it is our intention to move towards using solely a 12-month 

reporting period once the reporting periods for the 2013 and 2014 incentives conclude. 

Therefore, for payment adjustments occurring in 2017 and beyond, we propose to modify the 

regulation at newly designated §414.90(h) to specify only a 12-month reporting period occurring 

January 1—December 31, that falls 2 years prior to the applicability of the respective payment 

adjustment (for example, January 1, 2015 through December 31, 2015, for the 2017 payment 

adjustment). We invite public comment on the proposed reporting periods for the PQRS 

payment adjustments for 2015 and beyond. 

3. Proposed Requirements for the PQRS Reporting Mechanisms 

3. Proposed Requirements for the PQRS Reporting Mechanisms 

This section contains our proposals for the following reporting mechanisms: claims, 
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registry, EHR (including direct EHR products and EHR data submission vendor products), 

GPRO web-interface, and administrative claims. We previously established at §414.90(f)(2) that 

eligible professionals reporting individually may use the claims, registry, and EHR-based 

reporting mechanisms. We propose to modify §414.90 to allow group practices comprised of 2-

99 eligible professionals to use the claims, registry, and EHR-based reporting mechanisms as 

well, because we recognize the need to provide varied reporting criteria for smaller group 

practices, particularly since we are proposing to expand the definition of group practice. For 

example, we understand that a smaller group practice may not have a sufficiently varied practice 

to be able to meet the proposed satisfactory reporting criteria for the GPRO web-interface that 

would require a smaller group practice to report on all of the proposed PQRS quality measures 

specified in Table 35. These proposals are reflected in our proposed changes to §414.90, which 

we are proposing to re-designate §414.90(g) and §414.90(h). We invite public comment on this 

proposal to make the claims, registry, and EHR-based reporting options applicable to group 

practices. 

a. Claims-based Reporting: Proposed Requirements for Using Claims-based Reporting for 2013 

and Beyond 

Eligible professionals and group practices wishing to report data on PQRS quality 

measures via claims for the incentives and for the payment adjustments must submit quality data 

codes (QDCs) on claims to CMS for analysis. QDCs for the eligible professional's or group 

practice’s selected PQRS (individual or measures groups) quality measures that are reported on 

claims may be submitted to CMS at any time during the reporting period for the respective 

program year. However, as required by section 1848(m)(1)(A) of the Act, all claims for services 

furnished during the reporting period, would need to be processed by no later than the last Friday 

occurring two months after the end of the reporting period, to be included in the program year's 
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PQRS analysis. For example, all claims for services furnished during a reporting period that 

occurs during calendar year 2013 would need to be processed by no later than the last Friday of 

the second month after the end of the reporting period, that is, processed by February 28, 2014 

for the reporting periods that end December 31, 2013. In addition, after a claim has been 

submitted and processed, we propose at re-designated §414.90(g)(2)(i)(A) and newly added 

§414.90(h)(2)(i)(A) to indicate that EPs cannot submit QDCs on claims that were previously 

submitted and processed (for example, for the sole purpose of adding a QDC for the PQRS). We 

invite public comment on our proposed requirements for using the claims-based reporting 

mechanism for the incentives and for the payment adjustments for 2013 and beyond.

b. Registry-based Reporting 

(1) Proposed Qualification Requirements for Registries for 2013 and Beyond 

For 2013 and beyond, we propose that registries wishing to submit data on PQRS quality 

measures for a particular reporting period would be required to be qualified for each reporting 

period the registries wish to submit quality measures data. This qualification process is 

necessary to verify that registries are able to submit data on PQRS quality measures on behalf of 

eligible professionals and group practices to CMS. Registries who wish to become qualified to 

report PQRS quality measures for a reporting period undergo (1) a self-nomination process and 

(2) a qualification process regardless of whether the registry was qualified the previous program 

year. 

For the self-nomination process, we propose that the self-nomination process would 

consist of the submission of a self-nomination statement submitted via the web by January 31 of 

each year in which the registry seeks to submit data on PQRS quality measures on behalf of 

eligible professionals and group practices. For example, registries that wish to become qualified 

to report data in 2013 under the program, that is, to report during all of the reporting periods for 
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the 2013 incentive and the 2015 payment adjustment, would be required to submit its selfnomination statement by January 31, 2013. We propose that the self-nomination statement 

contain all of the following information: 

● The name of the registry. 

● The reporting period start date the registry will cover. 

● The measure numbers for the PQRS quality measures on which the registry is 

reporting. 

We note that CMS is currently developing the functionality to accept registry selfnomination statements via the web and anticipate development of this functionality to be 

complete for registries to submit their self-nomination statements via the web in 2013. However, 

in the event that it is not technically feasible to collect this self-nomination statement via the 

web, we propose that registry vendors would submit its self-nomination statement via a mailed 

letter to CMS. The self-nomination statement would be mailed to the following address: Centers 

for Medicare & Medicaid Services, Office of Clinical Standards and Quality, Quality 

Measurement and Health Assessment Group, 7500 Security Boulevard, Mail Stop S3-02-01, 

Baltimore, MD 21244-1850. We propose that these self-nomination statements must be received 

by CMS by 5:00 Eastern Standard Time on January 31 of the applicable year. 

For the qualification process, we propose that all registries, regardless of whether or not 

they have been qualified to report PQRS quality measures in a prior program year, undergo a 

qualification process to verify that the registry is prepared to submit data on PQRS quality 

measures for the reporting period in which the registry seeks to be qualified. To become 

qualified for a particular reporting period, we propose that a registry would be required to: 

● Be in existence as of January 1 the year prior to the program year in which the registry 

seeks qualification (for example, January 1, 2012, to be qualified to submit data in 2013). 
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● Have at least 25 participants by January 1 the year prior to the program year in which 

the registry seeks qualification (for example, January 1, 2012, to be qualified for the reporting 

periods occurring in 2013). 

● Provide at least 1 feedback report to participating eligible professionals and group 

practices for each program year in which the registry submits data on PQRS quality measures on 

behalf of eligible professionals and group practices. This feedback reporting would be based on 

the data submitted by the registry to CMS for the applicable reporting period or periods 

occurring during the program year. For example, if a registry was qualified for the reporting 

periods occurring in 2013, the registry would be required to provide a feedback report to all 

participating eligible professionals and group practices based on all 12 and 6-month reporting 

periods for the 2013 incentive and the 12-month reporting period for 2015 payment adjustment. 

Although we propose to require that qualified registries provide at least 1 feedback report to all 

participating eligible professionals and group practices, we encourage registries to provide an 

additional, interim feedback report, if feasible, so that an eligible professional may determine 

what steps, if any, are needed to meet the criteria for satisfactory reporting. 

● For purposes of distributing feedback reports to its participating eligible professionals 

and group practices, the registry must collect each participating eligible professional’s e-mail 

address and have documentation from each participating eligible professional authorizing the 

release of his or her e-mail address. 

● Not be owned or managed by an individual, locally-owned, single-specialty group (for 

example, single-specialty practices with only 1 practice location or solo practitioner practices 

would be precluded from becoming a qualified PQRS registry). 

● Participate in all ongoing PQRS mandatory support conference calls and meetings 

hosted by CMS for the program year in which the registry seeks to be qualified. For example, a 
CMS-1590-P 305 

registry wishing to be qualified for reporting in 2013 would be required to participate in all 

mandatory support conference calls hosted by CMS related reporting in 2013 under the PQRS. 

● Be able to collect all needed data elements and transmit to CMS the data at the 

TIN/NPI level for at least 3 measures. 

● Be able to calculate and submit measure-level reporting rates and/or, upon request, the 

data elements needed to calculate the reporting rates by TIN/NPI. 

● Be able to calculate and submit, by TIN/NPI, a performance rate (that is, the 

percentage of a defined population who receive a particular process of care or achieve a 

particular outcome based on a calculation of the measure’s numerator and denominator 

specifications) for each measure on which the eligible professional or group practice (as 

identified by the TIN/NPI) reports and/or, upon request, the Medicare beneficiary data elements 

needed to calculate the reporting rates. 

● Be able to separate out and report on Medicare Part B FFS patients. 

● Report the number of eligible instances (reporting denominator). 

● Report the number of instances a quality service is performed (reporting/performance 

numerator). 

● Report the number of performance exclusions, meaning the quality action was not 

performed for a valid reason as defined by the measure specification. 

● Report the number of reported instances, performance not met, meaning the quality 

action was not performed for any valid reason as defined by the measure specification. Please 

note that an eligible professional receives credit for reporting, not performance. 

● Be able to transmit data on PQRS quality measures in a CMS-approved XML format. 

● Comply with a CMS-specified secure method for data submission, such as submitting 

the registry's data in an XML file through an identity management system specified by CMS or 
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another CMS-approved method, such as use of appropriate Nationwide Health Information 

Network specifications, if technically feasible. 

● Submit an acceptable "validation strategy" to CMS by March 31 of the reporting year 

the registry seeks qualification (for example, if a registry wishes to become qualified for 

reporting in 2013, this validation strategy would be required to be submitted to CMS by March 

31, 2013). A validation strategy details how the registry will determine whether eligible 

professionals and group practices have submitted accurately and on at least the minimum number 

(80 percent) of their eligible patients, visits, procedures, or episodes for a given measure. 

Acceptable validation strategies often include such provisions as the registry being able to 

conduct random sampling of their participant's data, but may also be based on other credible 

means of verifying the accuracy of data content and completeness of reporting or adherence to a 

required sampling method. 

● Perform the validation outlined in the strategy and send the results to CMS by June 30 

of the year following the reporting period (for example, June 30, 2014, for data collected in the 

reporting periods occurring in 2013). 

● Enter into and maintain with its participating professionals an appropriate Business 

Associate agreement that provides for the registry's receipt of patient-specific data from the 

eligible professionals and group practices, as well as the registry's disclosure of quality measure 

results and numerator and denominator data and/or patient-specific data on Medicare 

beneficiaries on behalf of eligible professionals and group practices who wish to participate in 

the PQRS. 

● Obtain and keep on file signed documentation that each holder of an NPI whose data 

are submitted to the registry has authorized the registry to submit quality measure results and 

numerator and denominator data and/or patient-specific data on Medicare beneficiaries to CMS 
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for the purpose of PQRS participation. This documentation would be required to be obtained at 

the time the eligible professional signs up with the registry to submit PQRS quality measures 

data to the registry and would be required to meet any applicable laws, regulations, and 

contractual business associate agreements. 

● Upon request and for oversight purposes, provide CMS access to review the Medicare 

beneficiary data on which PQRS registry-based submissions are founded or provide to CMS a 

copy of the actual data. 

● Provide CMS a signed, written attestation statement via mail or e-mail which states 

that the quality measure results and any and all data including numerator and denominator data 

provided to CMS are accurate and complete. 

● Use PQRS measure specifications and the CMS provided measure calculation 

algorithm, or logic, to calculate reporting rates or performance rates unless otherwise stated. We 

will provide registries a standard set of logic to calculate each measure and/or measures group 

they intend to report for each reporting period. 

● Provide a calculated result using the CMS-supplied measure calculation logic and 

XML file format for each measure that the registry intends to calculate. The registries may be 

required to show that they can calculate the proper measure results (that is, reporting and 

performance rates) using the CMS-supplied logic and send the calculated data back to CMS in 

the specified format. The registries will be required to send in test files with fictitious data in the 

designated file format. 

● Describe to CMS the cost for eligible professionals and group practices that the 

registry charges to submit PQRS and/or eRx Incentive Program data to CMS. 

● Agree to verify the information and qualifications for the registry prior to posting 

(includes names, contact, measures, cost, etc.) and furnish/support all of the services listed for 
CMS-1590-P 308 

the registry on the CMS Website. 

● Agree that the registry's data for Medicare beneficiaries may be inspected or a copy 

requested by CMS and provided to CMS under our oversight authority. 

● Be able to report consistent with the satisfactory reporting criteria requirements for the 

PQRS incentives and payment adjustments. 

 In addition to meeting all the requirements specified previously for the reporting of 

individual quality measures via registry, for registries that intend to report on PQRS measures 

groups, we propose that these registries, regardless of whether or not registries were qualified in 

previous years, would be required to: 

● Indicate the reporting period chosen for each eligible professional who chooses to 

submit data on measures groups. 

● Base reported information on measures groups only on patients to whom services were 

furnished during the relevant reporting period. 

● If the registry is reporting using the measures group option for 20 patients, the registry 

on behalf of the eligible professional may include non-identifiable data for non-Medicare 

beneficiaries as long as these patients meet the denominator of the measure and the eligible 

professional includes a majority Medicare Part B patients in their cohort of 20 patients for the 

measures group. 

We intend to post the final list of registries qualified for each reporting period by the 

Summer of each the year in which the reporting periods occur on the CMS Website at 

http://http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/index.html. For example, we intend to post the list of registries qualified for 

2013 reporting periods by the Summer 2013. For each reporting period, the list of qualified 

registries would contain the following information: the registry name, registry contact 
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information, the measures and/or measures group(s) the registry is qualified and intends to report 

for the respective reporting period. 

This proposed registry qualification process is largely the same process we established to 

qualify registries for the reporting periods occurring in 2012. We are proposing a similar process 

to the 2012 qualification process because, registries are already familiar with this qualification 

process, so we believe there would be a greater likelihood that registries wishing to be qualified 

to report quality measures data for a particular reporting period would be able to pass the 

qualification process. We believe this will provide eligible professional with more qualified 

registry products from which to choose. 

Lastly, in the CY 2012 Medicare PFS proposed rule, we raised the issue of disqualifying 

registries that submit inaccurate data (76 FR 42845). We did not adopt a disqualification process 

but noted the importance of such a process, as well as our intention to provide detailed 

information regarding a disqualification process in future rulemaking (76 FR 73322). In an 

effort to ensure that registries provide accurate reporting of quality measures data, we propose to 

modify §414.90 to indicate that we would audit qualified registries. If, during the audit process, 

we find that a qualified registry has submitted grossly inaccurate data, we propose, under 

§414.90, to indicate that we would disqualify such a registry from the subsequent year under the 

program, meaning that a registry would not be allowed to submit PQRS quality measures data on 

behalf of eligible professionals and group practices for the next year. Under this proposal, a 

disqualified registry would not be included in the list of qualified registries that is posted for the 

applicable reporting periods under which the registry attempted to qualify. For example, if a 

qualified registry submits quality measures data for the reporting periods occurring in 2013 but is 

then audited and later disqualified, the registry would not be allowed to submit PQRS quality 

measures data on behalf of participating eligible professionals and group practices to CMS for 
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the reporting periods occurring in 2014 or later. One example of submitting grossly inaccurate 

data that CMS has encountered in the past is if a registry reports inaccurate TIN/NPIs on 5 

percent or more of the registry’s submission. As CMS calculates data on a TIN/NPI level, it is 

important for registries to provide correct TIN/NPI information. We invite public comment as to 

the threshold of grossly inaccurate data for the purpose of disqualifying a registry. 

Under our proposal, our decision to disqualify would be final. We further propose to post 

a registry’s disqualification status on the CMS Website at 

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/index.html. 

In proposing registry disqualification, we considered other alternatives, such as placing 

registries in a probationary status. However, we believe it is important for registries to submit 

correct data once it is qualified to submit data on behalf of its eligible professionals and 

therefore, find that immediate disqualification to be appropriate. This becomes especially 

important particularly as the program moves from the use of incentives to payment adjustments. 

We invite public comment on our proposals regarding registry qualification and 

disqualification for 2013 and beyond. 

In addition, the Nationwide Health Information Network (NwHIN) is an initiative 

developed by the Department of Health and Human Services that provides for the exchange of 

healthcare information. Traditionally, CMS has not collected data received via a registry through 

NwHIN. However, we strive to encourage the collection of data via the NwHIN and intend to do 

so when it is technically feasible to do so (as early as 2014). Therefore, we seek public comment 

on collecting data via registry for PQRS via NwHIN. 

c. EHR-based Reporting 

(1) Proposed Requirements for a Vendor’s Direct EHR Products for 2014 and Beyond 
CMS-1590-P 311 

We are proposing to modify §414.90(b) to define a direct electronic health record (EHR) 

product as “an electronic health record vendor’s product and version that submits data on 

Physician Quality Reporting System measures directly to CMS.” Please note that the selfnomination and qualification requirements for a vendor’s direct EHR products for 2012 and 2013 

were established in the CY 2012 Medicare PFS final rule (76 FR 73323). 

In lieu of continuing this process in future years of the program, we propose to no longer 

require qualification of EHR products in order to be used for reporting under the PQRS. 

Although we would still allow EHR vendors to submit test files to the PQRS and continue to 

provide support calls, we would no longer require vendors to undergo this testing process. 

Although vendors and their products would no longer be required to undergo this testing or 

qualification process, we propose that CMS would only accept the data if the data are: 

● Transmitted in a CMS-approved XML format utilizing a Clinical Document 

Architecture (CDA) standard such as Quality Reporting Data Architecture (QRDA) level 1 and 

● In compliance with a CMS-specified secure method for data submission, such as 

submitting the direct EHR vendor's data (for testing) through an identity management 

system specified by CMS or another approved method. 

In addition, upon request and for oversight purposes, we propose that the vendor would 

still be expected to provide CMS access to review the Medicare beneficiary data on which PQRS 

direct EHR-based submissions are founded or provide to CMS a copy of the actual data. CMS, 

however, would no longer be posting a list of qualified EHR vendors and their products on the 

CMS website. Therefore, eligible professionals would need to work with their respective EHR 

vendor to determine whether their specific EHR product has undergone any testing with the 

PQRS and/or whether their EHR product can produce and transmit the data in the CMS-specified 

format and manner. While we no longer believe that this process is necessary, we invite public 
CMS-1590-P 312 

comment as to whether CMS should continue to require that direct EHR products undergo selfnomination and qualification processes prior to being authorized to submit quality measures data 

to CMS for PQRS reporting purposes. 

We are proposing to not to continue the qualification requirement (that is, no longer 

propose this process for future years of the program) because we believe adequate checks are in 

place to ensure that a direct EHR product is able to submit quality measures data for the PQRS. 

For example, to the extent possible, we intend to align with the Medicare EHR Incentive 

Program with respect to our criteria for satisfactory reporting and measures available for 

reporting under the EHR-based reporting mechanism. The Medicare EHR Incentive Program 

requires that a vendor’s EHR system be certified under the program established by the Office of 

the National Coordinator for Health Information Technology (ONC). In future years, we 

anticipate that the ONC certification process could include testing related to the reporting of the 

proposed PQRS EHR measures indicated in Tables 32 and 33, since we are proposing to align 

the PQRS EHR-based measures with the measures available for reporting under the EHR 

Incentive Program. We invite public comment as to whether, in lieu of qualification, CMS 

should require that direct EHR products that would be used to submit data on PQRS quality 

measures for a respective reporting period be classified as certified under the program 

established by ONC. 

Please note that, regardless of whether the qualification process is in place and not 

withstanding any CEHRT requirements that may apply, we note that eligible professionals bear 

the burden of determining choosing a direct EHR product that is able to adequately submit PQRS 

quality measures data to CMS. 

We also invite public comment on the above proposals related to the proposed 

requirements for direct EHR products. 
CMS-1590-P 313 

In addition, the Nationwide Health Information Network (NwHIN) is an initiative 

developed by the Department of Health and Human Services that provides for the exchange of 

healthcare information. Traditionally, CMS has not collected data received via a direct EHR 

product through NwHIN, but we would like to encourage this method with EHR-based reporting. 

However, we strive to encourage the collection of data via the NwHIN and intend to do so when 

it is technically feasible to do so (as early as 2014). Therefore, we seek public comment on 

collecting data via an EHR for PQRS via NwHIN. 

 (2) Proposed Requirements for a Vendor’s EHR Data Submission Vendor Products for 2013 

and Beyond 

The EHR data submission vendor reporting mechanism was a mechanism that was newly 

established in the CY 2012 Medicare PFS final rule (76 FR 73324). We indicated that these 

EHR data submission vendors, some of which included previous registries, were entities that are 

able to receive and transmit clinical quality data extracted from an EHR to CMS. We propose to 

modify §414.90(b) to define an electronic health record (EHR) data submission vendor as “an 

electronic health record vendor’s product and version that acts as an intermediary to submit data 

on Physician Quality Reporting System measures on behalf of an eligible professional or group 

practice.” 

Please note that the qualification requirements for a vendor’s EHR data submission 

vendor products for 2013 were established in the CY 2012 Medicare PFS final rule (76 FR 

73327). Specifically, we established that a qualification and testing process would occur in 2012 

to qualify EHR data submission vendor products to submit PQRS quality measures data for 

reporting periods occurring in CY 2013. Operationally, we were unable to establish a 

qualification and testing process in 2012 to qualify EHR data submission vendor products for 

reporting periods occurring in CY 2013. Therefore, we propose to perform, in 2013, the 
CMS-1590-P 314 

qualification and testing process established in the CY 2012 Medicare PFS final rule (76 FR 

73327) that was supposed to occur in 2012. We invite public comment on this proposal. 

As for 2014 and beyond, we propose to no longer qualify EHR data submission vendor 

products in order to use such products under the PQRS for the same reasons we have articulated 

in our proposal not to continue qualifying direct EHR products. Although we would still allow 

EHR data submission vendors to submit test files to the PQRS and continue to provide support 

calls, we would no longer require vendors to undergo this testing process. Although EHR data 

submission vendor products would no longer be required to undergo this testing or qualification 

process, we propose that CMS would only accept the data if the data are: 

● 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 vendors who 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 

● In compliance with a CMS-specified secure method for data submission. 

 In addition, upon request and for oversight purposes, we propose that the vendor would 

still be expected to provide CMS access to review the Medicare beneficiary data on which PQRS 

direct EHR-based submissions are founded or provide to CMS a copy of the actual data. CMS, 

however, would no longer be posting a list of qualified EHR data submission vendors on the 

CMS website. Therefore, eligible professionals would need to work with their respective EHR 

data submission vendor to determine whether the vendor has undergone any testing with the 

PQRS and/or whether EHR data submission vendor can produce and transmit the data in the 

CMS-specified format and manner. 

We invite public comment on our proposal to, beginning 2014, not require qualification 
CMS-1590-P 315 

of EHR data submission vendor products. We also invite public comment as to whether CMS 

should continue to require that EHR data submission vendor products undergo these selfnomination and qualification processes prior to being authorized to submit quality measure data 

to CMS on an eligible professional’s behalf for PQRS reporting purposes. 

We are proposing to not to continue the qualification requirement (that is, no longer 

propose this process for 2014 and future years of the program) because we believe adequate 

checks are in place to ensure that a direct EHR product is able to submit quality measures data 

for the PQRS. For example, to the extent possible, we intend to align with the Medicare EHR 

Incentive Program with respect to our criteria for satisfactory reporting and measures available 

for reporting under the EHR-based reporting mechanism. The Medicare EHR Incentive Program 

requires that a vendor’s EHR system be certified under the program established by the Office of 

the National Coordinator for Health Information Technology (ONC). In future years, we 

anticipate that the ONC certification process could include testing related to the reporting of the 

proposed PQRS EHR measures indicated in Tables 32 and 33, since we are proposing to align 

the PQRS EHR-based measures with the measures available for reporting under the EHR 

Incentive Program. We invite public comment as to whether, in lieu of qualification, CMS 

should require that EHR data submission vendor products wishing to submit data on PQRS 

quality measures for a respective reporting period be certified under the program established by 

ONC. 

Please note that, if the qualification process is no longer required or we do not require 

that an EHR data submission vendor product be certified under ONC’s program, we note that 

eligible professionals bear the burden of determining choosing an EHR data submission vendor 

product that is able to adequately submit PQRS quality measures data to CMS. 

In addition, the Nationwide Health Information Network (NwHIN) is an initiative 
CMS-1590-P 316 

developed by the Department of Health and Human Services that provides for the exchange of 

healthcare information. Traditionally, CMS has not collected data received via an EHR data 

submission vendor through NwHIN, but we would like to encourage this method with EHRbased reporting. However, we strive to encourage the collection of data via the NwHIN and 

intend to do so when it is technically feasible to do so (as early as 2014). Therefore, we seek 

public comment on collecting data via an EHR for PQRS via NwHIN. 

d. GPRO Web-Interface: Proposed Requirements for Group Practices Using the GPRO WebInterface for 2013 and Beyond 

The GPRO web-interface is a reporting mechanism established by CMS that is used by 

group practices that are selected to participate in the GPRO. For 2013 and beyond, we propose 

to modify newly designated §414.90(g) and §414.90(h) to identify the GPRO web-interface as a 

reporting mechanism available for reporting under the PQRS by group practices comprised of 25 

or more eligible professionals. Consistent with the GPRO satisfactory reporting criteria we 

established for the 2012 PQRS (76 FR 73338), as well as the GPRO satisfactory reporting 

criteria we are proposing for 2013 and beyond, we propose to limit reporting via the GPRO webinterface during a respective reporting period to group practices comprised of at least 25 eligible 

professionals (that is, this reporting option would not be available to group practices that contain 

2-24 eligible professionals) and selected to participate in the GPRO for the year under which the 

reporting period occurs. For example, a group practice wishing to submit quality measure data 

via the GPRO web-interface for 2013 must be a group practice selected to participate in the 

GPRO for the 2013 program year. We believe it is necessary to limit use of the GPRO webinterface to group practices comprised of at least 25 eligible professionals selected to participate 

in the GPRO because the 17 measures that are proposed to be reportable via the GPRO webinterface (as specified in Table 35) reflect a variety of disease modules: patient/ caregiver 
CMS-1590-P 317 

experience, care coordination/patient safety, preventive health, diabetes, hypertension, ischemic 

vascular disease, heart failure, and coronary artery disease. 

We believe that the reporting of these 18 proposed measures spanning across various 

settings lends this reporting mechanism more ideal for larger group practices that are more likely 

to be multi-specialty practices (which are typically group practices consisting of larger than 25 

eligible professionals). The GPRO web-interface was modeled after the CMS Physician Group 

Practice (PGP) demonstration, and this demonstration was originally intended for large group 

practices. From our experience with the PGP demonstration, we believe a group practice 

comprised of 25 eligible professionals is the smallest group practice that could benefit from use 

of the GPRO web-interface as a reporting mechanism. We also do not believe that excluding 

group practices comprised of 2-24 eligible professionals from using the GPRO web-interface as 

a reporting mechanism would harm these smaller group practices as we are proposing to allow 

groups comprised of 2-99 eligible professionals to report using the claims, qualified registry, 

EHR, and administrative claims-based reporting mechanisms. 

We propose to provide group practices that are selected to participate in the GPRO using 

GPRO web-interface reporting option with access to the GPRO web-interface by no later than 

the first quarter of the year following the end of the reporting period under which the group 

practice intends to report. For example, for group practices selected for the GPRO for the 2013 

incentive using the GPRO web-interface tool, we propose to provide group practices selected to 

participate in the GPRO with access to the GPRO web-interface by no later than the first quarter 

of 2014 for purposes of reporting for the applicable 2013 reporting period for the incentive. In 

addition, should CMS encounter operational issues with using the GPRO web-interface, we 

reserve the right to use a similar tool for group practices to use in lieu of reporting via the GPRO 
CMS-1590-P 318 

web-interface. We invite public comment on our proposed requirements for group practices 

using the GPRO web-interface for 2013 and beyond. 

In addition, the Nationwide Health Information Network (NwHIN) is an initiative 

developed by the Department of Health and Human Services that provides for the exchange of 

healthcare information. Traditionally, CMS has not collected data received via the GPRO webinterface through NwHIN. However, we strive to encourage the collection of data via the 

NwHIN and intend to do so when it is technically feasible to do so (as early as 2014). Therefore, 

we seek public comment on collecting data via the GPRO web-interface for PQRS via NwHIN. 

e. Administrative Claims 

 For purposes of reporting for the 2015 and 2016 PQRS payment adjustments only, we 

propose to modify §414.90(h) to allow eligible professionals and group practices to use an 

administrative claims reporting mechanism. The administrative claims reporting mechanism 

builds off of the traditional PQRS claims-based reporting mechanism. Under the traditional 

PQRS claims-based reporting mechanism, eligible professionals and group practices wishing to 

report data on PQRS quality measures via claims for the incentives and for the payment 

adjustments must submit quality data codes (QDCs) on claims to CMS for analysis. Under the 

proposed administrative claims reporting mechanism, unlike the traditional claims-based 

reporting option, an eligible professional or group practice would not be required to submit 

QDCs on claims to CMS for analysis. Rather, CMS would analyze every eligible professional’s 

or group practice’s patient’s Medicare claims to determine whether the eligible professional or 

group practice has performed any of the clinical quality actions indicated in the proposed PQRS 

quality measures in Table 63. We propose that, for purposes of assessing claims for quality 

measures under this option, all claims for services furnished that occurs during the 2015 and/or 

2016 PQRS reporting period would need to be processed by no later than 60 days after the end of 
CMS-1590-P 319 

the respective 2015 and 2016 payment adjustment reporting periods (that is, December 31, 2013 

and December 31, 2014). We invite public comment on our proposed requirements for using the 

administrative claims-based reporting mechanism for the 2015 and 2016 payment adjustments.

4. Proposed Criteria for Satisfactory Reporting for the 2013 and 2014 Incentives 

For 2013 and 2014, in accordance with §414.90(c)(3), eligible professionals that 

satisfactorily report data on PQRS quality measures are eligible to receive an incentive equal to 

0.5 percent of the total estimated Medicare Part B allowed charges for all covered professional 

services furnished by the eligible professional or group practice during the applicable reporting 

period. This section contains our proposed criteria for satisfactory reporting for the 2013 and 

2014 incentives, which are the last two incentives authorized under the PQRS. 

a. Proposed Criteria for Satisfactory Reporting for Individual Eligible Professionals 

Please note that, in large part, we are proposing many of the same criteria for satisfactory 

reporting for individual eligible professionals for the 2013 and 2014 incentives that we 

established for the 2012 incentive, as eligible professionals are already familiar with these 

reporting criteria. 

(1) Proposed Criteria for Satisfactory Reporting on Individual PQRS Quality Measures via 

Claims 

According to the “2010 Physician Quality Reporting System and eRx Reporting 

Experience and Trends,” available for viewing in the “downloads” section of the main page the 

PQRS website (http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/index.html), reporting via the claims-based reporting mechanism was the 

most commonly used reporting method. We believe that this trend continues, so we anticipate 

that, with respect to the 2013 and 2014 incentives, the criteria for satisfactory reporting for the 

claims-based reporting mechanism will be the method most widely used by individual eligible 
CMS-1590-P 320 

professionals. So as not to change reporting criteria that a large number of individual eligible 

professionals are familiar with using, we established the same reporting criteria for the 2011 and 

2012 incentives (76 FR 73330). Therefore, for the respective 12-month reporting periods for the 

2013 and 2014 incentives, based on our authority under section 1848(m)(3)(D) of the Act to 

revise the reporting criteria for satisfactory reporting specified under the statute and our desire to 

maintain the same reporting criteria we established for individual eligible professionals for the 

2012 PQRS incentive (76 FR 73330), we propose the following criteria for satisfactory reporting 

of PQRS individual measures for individual eligible professionals using the claims-based 

reporting mechanism: Report at least 3 measures, OR, if less than 3 measures apply to the 

eligible professional, report 1—2 measures, AND report each measure for at least 50 percent of 

the eligible professional’s Medicare Part B FFS patients seen during the reporting period to 

which the measure applies. Measures with a 0 percent performance rate would not be counted. 

For an eligible professional who reports fewer than 3 measures via the claims-based reporting 

mechanism, we propose that the eligible professional be subject to the Measures Applicability 

Validation (MAV) process, which would allow us to determine whether an eligible professional 

should have reported quality data codes for additional measures. We believe the MAV process is 

necessary to review whether there are other closely related measures (such as those that share a 

common diagnosis or those that are representative of services typically provided by a particular 

type of eligible professional). Under the MAV process, if an eligible professional who reports 

on fewer than 3 measures reports on a measure that is part of an identified cluster of closely 

related measures, then the eligible professional would not qualify as a satisfactory reporter for 

the 2013 and/or 2014 incentives. We are proposing this MAV process for the claims-based 

reporting mechanism only because it is more likely for EPs to report on more than 3 measures 

under the registry and EHR-based reporting mechanisms, as a registry or EHR product will 
CMS-1590-P 321 

typically automatically report on all measures that apply to the eligible professional’s practice. 

We note that, consistent with section 1848(m)(3)(A)(i) of the Act, this proposed claims-based 

reporting criteria is the only proposed criteria where an eligible professional may report on fewer 

than 3 measures. We invite public comment on the proposed criteria for satisfactory reporting of 

individual measures by individual eligible professionals via claims for the 2013 and 2014 

incentives. 

(2) Proposed Criteria for Satisfactory Reporting on Individual PQRS Quality Measures via 

Registry 

In addition, we note that section 1848(m)(3)(A)(ii) of the Act provides that, to meet the 

criteria for satisfactory reporting under PQRS, an eligible professional would be required to 

report on at least 3 measures for at least 80 percent of the cases in which the respective measure 

is reportable under the system. Although we have the authority under section 1848(m)(3)(D) of 

the Act to revise the criteria for satisfactory reporting, with respect to registry-based reporting, 

we have largely followed these reporting criteria for the PQRS incentives. According to the 

“2010 Physician Quality Reporting System and eRx Reporting Experience and Trends,” eligible 

professionals are more likely to meet the requirements for a PQRS incentive using the 

satisfactory reporting criteria for the registry-based reporting mechanism than claims. In fact, in 

2010, approximately 87 percent of the eligible professionals reporting individual PQRS quality 

measures via registry were eligible and met the criteria for satisfactory reporting for the 2010 

incentive. Since eligible professionals have had success with using these satisfactory reporting 

criteria, we believe such criteria are appropriate and see no reason to change the criteria for 

satisfactory reporting via registry that has been in place since 2010. Therefore, for those reasons 

and our desire to maintain the same reporting criteria we established for individual eligible 

professionals for the 2012 PQRS incentive (76 FR 73331), we propose the following criteria for 
CMS-1590-P 322 

satisfactory reporting of PQRS individual measures for individual eligible professionals using 

the registry-based reporting mechanism for the 12-month reporting periods for the 2013 and 

2014 incentives, respectively: report at least 3 measures AND report each measure for at least 

80 percent of the eligible professional’s Medicare Part B FFS patients seen during the reporting 

period to which the measure applies. Measures with a zero percent performance rate will not be 

counted. Measures with a zero percent performance rate will not be counted. We invite public 

comment on the proposed criteria for satisfactory reporting of individual measures by individual 

eligible professionals via a registry for the 2013 and 2014 incentives. 

(3) Proposed Criteria for Satisfactory Reporting on Individual PQRS Quality Measures via EHR 

 As stated previously, section 1848(m)(7) of the Act requires us to develop a plan to 

integrate reporting requirements for PQRS and the EHR Incentive Program. Therefore, with 

respect to EHR-based reporting, it is our main goal to align our EHR reporting requirements with 

the reporting requirements an eligible professional must meet in order to satisfy the clinical 

quality measure (CQM) component of meaningful use (MU) under the EHR Incentive Program. 

In the EHR Incentive Program – Stage 2 NPRM (77 FR 13698), we proposed the CQM reporting 

requirements for the EHR Incentive Program for 2013, 2014, 2015, and potentially subsequent 

years. For the EHR reporting periods in CY 2013, we proposed (77 FR 13745) to continue the 

CQM reporting requirements that were established for eligible professionals for CYs 2011 and 

2012 in the EHR Incentive Program – Stage 1 final rule (75 FR 44398-44411). Therefore, to 

align with the reporting requirements for meeting the CQM component of meaningful use, and 

based on our authority under section 1848(m)(3)(D) of the Act to revise the reporting criteria for 

satisfactory reporting identified under the statute, we propose the following criteria for the 12-

month reporting period for the 2013 incentive: 
CMS-1590-P 323 

● As required by the Stage 1 final rule, eligible professionals must report on three 

Medicare EHR Incentive Program core or alternate core measures, plus three additional 

measures. The EHR Incentive Program’ core, alternate core, and additional measures can be 

found in Table 6 of the EHR Incentive Program’s Stage 1 final rule (75 FR 44398) or in Tables 

32 and 33 of this section. We refer readers to the discussion in the Stage 1 final rule for further 

explanation of the requirements for reporting those CQMs (75 FR 44398 through 44411). 

 Under this proposal, eligible professionals using these reporting criteria would be 

required to report on 6 measures. For the proposed PQRS EHR measures that are also Medicare 

EHR Incentive Program core, alternate core, or additional measures that the eligible professional 

reports (75 FR 44398 through 44411), an eligible professional would be required to report the 

applicable measure for 100 percent of the eligible professionals Medicare Part B FFS patients. 

 In addition, we note that section 1848(m)(3)(A)(ii) of the Act provides that, to meet the 

criteria for satisfactory reporting under PQRS, an eligible professional would be required to 

report on at least 3 measures for at least 80 percent of the cases in which the respective measure 

is reportable under the system. Although we have the authority under section 1848(m)(3)(D) of 

the Act to revise the criteria for satisfactory reporting, for EHR-based reporting, we have largely 

kept these reporting criteria for the 2010—2012 incentives. As we have seen some eligible 

professionals succeed with these criteria, we are proposing the following similar criteria for the 

12-month reporting period for the 2013 incentive: report at least 3 measures AND report each 

measure for at least 80 percent of the eligible professional’s Medicare Part B FFS patients seen 

during the reporting period to which the measure applies. Measures with a zero percent 

performance rate will not be counted. 

 We note that the Medicare EHR Incentive Program has proposed options for meeting the 

CQM component of achieving meaningful use beginning with CY 2014 (for more information 
CMS-1590-P 324 

on these options, please see 77 FR 13746—13748). To align our EHR-based reporting 

requirements with those proposed under the Medicare EHR Incentive Program, we are proposing 

the following criteria for satisfactory reporting using the EHR-based reporting mechanism for the 

12-month reporting period for the 2014 incentive: 

● Option 1a: Select and submit 12 clinical quality measures available for EHR-based 

reporting from Tables 32 and 33, including at least 1 measure from each of the following 6 

domains – (1) patient and family engagement, (2) patient safety, (3) care coordination, (4) 

population and public health, (5) efficient use of healthcare resources, and (6) clinical 

process/effectiveness. 

● Option 1b: Submit 12 clinical quality measures composed of all 11 of the proposed 

Medicare EHR Incentive Program core clinical quality measures specified in Tables 32 and 33 

plus 1 menu clinical quality measure from Tables 32 and 33. It is our intention to finalize the 

reporting criteria that aligns with the criteria that will be established for meeting the CQM 

component of meaningful use beginning with CY 2014 for the Medicare EHR Incentive 

Program. Furthermore, to the extent that the final criteria for meeting the CQM component of 

achieving meaningful use differ from what was proposed, our intention is to align with the 

reporting criteria the EHR Incentive Program ultimately establishes. Therefore, eligible 

professionals who participate in both PQRS and the EHR Incentive Program would be able to 

use one reporting criterion, during overlapping reporting periods, to satisfy the satisfactory 

reporting criteria under PQRS and the CQM component of meaningful use under the Medicare 

EHR Incentive Program. We invite public comment on this considered proposal. 

 In addition to this proposed criterion, the Medicare EHR Incentive Program proposed 

that, beginning with CY 2014, eligible professionals who participate in both the Physician 

Quality Reporting System and the Medicare EHR Incentive Program may satisfy the CQM 
CMS-1590-P 325 

component of meaningful use if they submit and satisfactorily report Physician Quality 

Reporting System clinical quality measures under the Physician Quality Reporting System’s 

EHR reporting option using Certified EHR Technology (77 FR 13748). Since this language 

suggests that the Medicare EHR Incentive Program may defer to the satisfactory reporting 

criteria for the EHR-based reporting mechanism that we will establish for 2014, we are 

proposing the following reporting criteria for the 12-month reporting period for the 2014 

incentive that largely conform to the criteria set forth under section 1848(m)(3)(A)(ii) of the Act 

that we established for the 2012 incentive and that we are proposing for the 2013 incentive: 

report at least 3 measures AND report each measure for at least 80 percent of the eligible 

professional’s Medicare Part B FFS patients seen during the reporting period to which the 

measure applies. Measures with a zero percent performance rate will not be counted. We invite 

public comment on the proposed criteria for satisfactory reporting on PQRS measures via EHR. 

(4) Proposed Criteria for Satisfactory Reporting on PQRS Measures Groups via Claims 

 In the CY 2012 Medicare PFS final rule, we established the following criteria for 

satisfactorily reporting PQRS measures groups for the 12-month reporting period for the 2012 

incentive (76 FR 73335): 

● Report at least 1 PQRS measures group, AND report each measures group for at least 

30 Medicare Part B FFS patients. Measures groups containing a measure with a 0 percent 

performance rate will not be counted; OR 

● Report at least 1 PQRS measures group, AND report each measures group for at least 

50 percent of the eligible professional’s Medicare Part B FFS patients seen during the reporting 

period to whom the measures group applies; BUT report each measures group on no less than 15 

Medicare Part B FFS patients seen during the reporting period to which the measures group 

applies. Measures groups containing a measure with a 0 percent performance rate will not be 
CMS-1590-P 326 

counted. 

 We received stakeholder feedback that it is difficult for some specialties to meet the 30 

Medicare Part B FF patient threshold. Therefore, based on our authority under section 

1848(m)(3)(D) of the Act to revise the reporting criteria for satisfactory reporting, we propose 

the following criteria for the satisfactory reporting PQRS measures groups for individual 

eligible professionals using the claims-based reporting mechanism for the 12-month reporting 

periods for the 2013 and 2014 incentives: Report at least 1 measures group AND report each 

measures group for at least 20 Medicare Part B FFS patients. Measures groups containing a 

measure with a zero percent performance rate will not be counted. 

 We note that, in an effort to simplify the satisfactory reporting criteria, we are only 

proposing 1 option for meeting the criteria for satisfactory reporting using PQRS measures 

groups via claims. We invite public comment on the proposed criterion for satisfactory reporting 

of measures groups via claims for the 2013 and 2014 incentives. 

(5) Proposed Criteria for Satisfactory Reporting on PQRS Measures Groups via Registry 

In the CY 2012 Medicare PFS final rule, we established the following criteria for 

satisfactorily reporting PQRS measures groups for the 12-month reporting period for the 2012 

incentive (76 FR 73337): 

● Report at least 1 PQRS measures group AND report each measures group for at least 

30 Medicare Part B FFS patients. Measures groups containing a measure with a 0 percent 

performance rate will not be counted; OR 

● Report at least 1 PQRS measures group, AND report each measures group for at least 

80 percent of the eligible professional’s Medicare Part B FFS patients seen during the reporting 

period to whom the measures group applies; BUT report each measures group on no less than 15 

Medicare Part B FFS patients seen during the reporting period to which the measures group 
CMS-1590-P 327 

applies. Measures groups containing a measure with a 0 percent performance rate will not be 

counted. 

In addition, we established the following criteria for satisfactorily reporting PQRS 

measures groups for the 6-month reporting period for the 2012 incentive (76 FR 73337): Report 

at least 1 PQRS measures group, AND report each measures group for at least 80 percent of the 

eligible professional’s Medicare Part B FFS patients seen during the reporting period to whom 

the measures group applies; BUT report each measures group on no less than 8 Medicare Part B 

FFS patients seen during the reporting period to which the measures group applies. Measures 

groups containing a measure with a 0 percent performance rate will not be counted. 

We received stakeholder feedback that it is difficult for some specialties to meet the 30 

Medicare Part B FF patient threshold. Therefore, based on our authority under section 

1848(m)(3)(D) of the Act to revise the reporting criteria for satisfactory reporting, we propose 

the following criteria for satisfactory reporting of PQRS measures groups for individual eligible 

professionals using the registry-based reporting mechanism for the 2013 and 2014 incentives: 

(1) For the 12-month reporting periods for the respective 2013 and 2014 incentives, 

report at least 1 measures group, AND report each measures group for at least 20 patients, a 

majority of which must be Medicare Part B FFS patients. Measures groups containing a measure 

with a 0 percent performance rate will not be counted. 

(2) For the 6-month reporting period for the respective 2013 and 2014 incentives, report 

at least 1 measures group, AND report each measures group for at least 20 patients, a majority of 

which must be Medicare Part B FFS patients. Measures group containing a measure with a zero 

percent performance rate will not be counted. Please note that this is the same criterion 

established for the 12-month reporting period. We are proposing the same criterion for both 

reporting periods in an effort to simplify the reporting criterion for satisfactory reporting. 
CMS-1590-P 328 

We note that, while we still are proposing to require that an eligible professional report 

on at least 20 patients, we understand that a patient’s personal identification information may be 

stripped when data is collected via a qualified registry. As such, we understand that it may be 

difficult to distinguish Medicare and non-Medicare patients. Given this difficulty and that the 

eligible professionals generally would be attempting to report data on Medicare patients, we 

believe the reporting of some non-Medicare patients could serve a proxy for the reporting of 

Medicare patients whose data is not easily distinguishable as data on Medicare patients under 

this reporting mechanism. 

Finally, we note that these proposals would satisfy the requirement under section 

1848(m)(5)(F) of the Act that we provide for alternative reporting periods and criteria for 

satisfactory reporting with regard to measures groups and registry-based reporting. We invite 

public comment on the proposed criteria for satisfactory reporting of measures groups by 

individual eligible professionals via registry for the 2013 and 2014 incentives. 

Tables 25 and 26 provide a summary of our proposals for the satisfactory reporting of 

PQRS quality measures for the 2013 and 2014 incentives. 

Table 25: Proposed Criteria for Satisfactory Reporting by Individual Eligible Professionals 

of Data on PQRS Quality Measures for the 2013 Incentive 

Reporting 

Period 

Measure 

Type 

Reporting 

Mechanism 

Proposed Reporting Criteria 

Jan 1, 

2013—

Dec 31, 

2013* 

Individual 

Measures 

Claims Report at least 3 measures, OR, 

If less than 3 measures apply to the eligible professional, report 1—2 

measures*; AND 

Report each measure for at least 50 percent of the eligible professional’s 

Medicare Part B FFS patients seen during the reporting period to which 

the measure applies. 

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

Jan 1, 

2013—

Dec 31, 

2013 

Individual 

Measures 

Qualified 

Registry 

Report at least 3 measures, AND 

Report each measure for at least 80 percent of the eligible professional’s 

Medicare Part B FFS patients seen during the reporting period to which 

the measure applies. 

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

Jan 1, 

2013—

Dec 31, 

2013 

Individual 

Measures 

Direct EHR 

Product 

Option 1: Report on ALL three PQRS EHR measures that are also 

Medicare EHR Incentive Program core measures. 

If the denominator for one or more of the Medicare EHR Incentive 

Program core measures is 0, report on up to three PQRS EHR measures 

that are also Medicare EHR Incentive Program alternate core measures; 
CMS-1590-P 329 

Reporting 

Period 

Measure 

Type 

Reporting 

Mechanism 

Proposed Reporting Criteria 

AND 

Report on three additional PQRS EHR measures that are also measures 

available for the Medicare EHR Incentive Program 

Option 2: Report at least 3 measures, AND 

Report each measure for at least 80 percent of the eligible professional’s 

Medicare Part B FFS patients seen during the reporting period to which 

the measure applies. 

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

Jan 1, 

2013—

Dec 31, 

2013 

Individual 

Measures 

EHR Data 

Submission 

Vendor 

Option 1: Report on ALL three PQRS EHR measures that are also 

Medicare EHR Incentive Program core measures. 

If the denominator for one or more of the Medicare EHR Incentive 

Program core measures is 0, report on up to three PQRS EHR measures 

that are also Medicare EHR Incentive Program alternate core measures; 

AND 

Report on three additional PQRS EHR measures that are also measures 

available for the Medicare EHR Incentive Program 

Option 2: Report at least 3 measures, AND 

Report each measure for at least 80 percent of the eligible professional’s 

Medicare Part B FFS patients seen during the reporting period to which 

the measure applies. 

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

Jan 1, 

2013—

Dec 31, 

2013 

Measures 

Groups 

Claims Report at least 1 measures group, AND 

Report each measures group for at least 20 Medicare Part B FFS 

patients. Measures groups containing a measure with a 0 percent 

performance rate will not be counted. 

Jan 1, 

2013—

Dec 31, 

2013 

Measures 

Groups 

Qualified 

Registry 

Report at least 1 measures group, AND 

Report each measures group for at least 20 patients, a majority of which 

must be Medicare Part B FFS patients. 

Measures groups containing a measure with a 0 percent performance 

rate will not be counted 

Jul 1, 

2013—

Dec 31, 

2013 

Measures 

Groups 

Qualified 

Registry 

Report at least 1 measures group, AND 

Report each measures group for at least 20 patients, a majority of which 

must be Medicare Part B FFS patients. 

Measures groups containing a measure with a 0 percent performance 

rate will not be counted 

* Subject to the measure applicability validation (MAV) process. 

Table 26: Proposed Criteria for Satisfactory Reporting by Individual Eligible Professionals 

of Data on PQRS quality measures for the 2014 Incentive 

Reporting 

Period 

Measure 

Type 

Reporting 

Mechanism Proposed Reporting Criteria 

Jan 1, 

2014—

Dec 31, 

2014* 

Individual 

Measures 

Claims Report at least 3 measures, OR, 

If less than 3 measures apply to the eligible professional, report 1—2 

measures*; AND 

Report each measure for at least 50 percent of the eligible professional’s 

Medicare Part B FFS patients seen during the reporting period to which 

the measure applies. 

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

Jan 1, 

2014—

Dec 31, 

2014 

Individual 

Measures 

Qualified 

Registry 

Report at least 3 measures, AND 

Report each measure for at least 80 percent of the eligible professional’s 

Medicare Part B FFS patients seen during the reporting period to which 

the measure applies. 

Measures with a 0 percent performance rate will not be counted. 
CMS-1590-P 330 

Reporting 

Period 

Measure 

Type 

Reporting 

Mechanism Proposed Reporting Criteria 

Jan 1, 

2014—

Dec 31, 

2014 

Individual 

Measures 

Direct EHR 

product 

Option 1a: Select and submit 12 clinical quality measures available for 

EHR-based reporting from Tables 32 and 33, including at least 1 

measure from each of the following 6 domains – (1) patient and family 

engagement, (2) patient safety, (3) care coordination, (4) population and 

public health, (5) efficient use of healthcare resources, and (6) clinical 

process/effectiveness. 

Option 1b: Submit 12 clinical quality measures composed of all 11 of 

the proposed Medicare EHR Incentive Program core clinical quality 

measures specified in Tables 32 and 33plus 1 menu clinical quality 

measure from Tables 32 and 33. 

Option 2: Report at least 3 measures AND report each measure for at 

least 80 percent of the eligible professional’s Medicare Part B FFS 

patients seen during the reporting period to which the measure applies. 

Measures with a zero percent performance rate will not be counted. 

Jan 1, 

2014—

Dec 31, 

2014 

Individual 

Measures 

EHR data 

submission 

vendor 

Option 1a: Select and submit 12 clinical quality measures available for 

EHR-based reporting from Tables 32 and 33, including at least 1 

measure from each of the following 6 domains – (1) patient and family 

engagement, (2) patient safety, (3) care coordination, (4) population and 

public health, (5) efficient use of healthcare resources, and (6) clinical 

process/effectiveness. 

Option 1b: Submit 12 clinical quality measures composed of all 11 of 

the proposed Medicare EHR Incentive Program core clinical quality 

measures specified in Tables 32 and 33plus 1 menu clinical quality 

measure from Tables 32 and 33. 

Option 2: Report at least 3 measures AND report each measure for at 

least 80 percent of the eligible professional’s Medicare Part B FFS 

patients seen during the reporting period to which the measure applies. 

Measures with a zero percent performance rate will not be counted. 

Jan 1, 

2014—

Dec 31, 

2014 

Measures 

Groups 

Claims Report at least 1 measures group, AND 

Report each measures group for at least 20 Medicare Part B FFS 

patients. 

Measures groups containing a measure with a 0 percent performance 

rate will not be counted. 

Jan 1, 

2014—

Dec 31, 

2014 

Measures 

Groups 

Qualified 

Registry 

Report at least 1 measures group, AND 

Report each measures group for at least 20 patients, a majority of which 

must be Medicare Part B FFS patients. 

Measures groups containing a measure with a 0 percent performance 

rate will not be counted. 

Jul 1, 

2014—

Dec 31, 

2014 

Measures 

Groups 

Qualified 

Registry 

Report at least 1 measures group, AND 

Report each measures group for at least 20 patients, a majority of which 

must be Medicare Part B FFS patients. 

Measures groups containing a measure with a 0 percent performance 

rate will not be counted. 

* Subject to the measure applicability validation (MAV) process. 

b. Proposed Criteria for Satisfactory Reporting for Group Practices Selected to Participate in the 

GPRO 

This section contains our proposed criteria for satisfactory reporting for group practices 
CMS-1590-P 331 

selected to participate in the GPRO for the 2013 and 2014 incentives, which are the last two 

incentives authorized under the Physician Quality Reporting System. Please note that, in 

addition to offering the GPRO web-interface tool that we’ve previously included under the 

program, we are proposing new criteria for group practices under the GPRO that allow group 

practices to use the claims, registry, and EHR-based reporting mechanisms. In prior program 

years, large group practices have been successful in reporting quality measures data via the 

GPRO web-interface. We are proposing new criteria under the claims, qualified registry, and 

EHR-based reporting mechanisms because we believe that smaller groups may benefit from 

different reporting criteria and also other reporting mechanisms. Since the introduction of 

smaller group practices comprised of 25-99 eligible professionals under the GPRO is fairly 

recent, and given that we are proposing to modify the definition for group practice such that the 

PQRS GPRO would include beginning in 2013 group practices comprised of 2-24 eligible 

professionals, we are proposing additional criteria for reporting because we believe it may be 

more practicable that smaller group practices report on PQRS quality measures via claims, 

qualified registry, or direct EHR or EHR data submission vendor versus the GPRO webinterface, which was designed for use by larger group practices. 

(1) Proposed Criteria for Beneficiary Assignment Methodology and Satisfactory Reporting on 

PQRS Quality Measures via the GPRO Web-Interface 

In order to populate the GPRO web-interface, we must first assign beneficiaries to each 

group practice and then from those assigned beneficiaries draw a sample of beneficiaries for the 

disease modules in the GPRO web interface. This assignment and sampling methodology is 

based on what we learned from the PGP demonstration. The PGP demonstration aims to 

encourage coordination of the care furnished to individuals under Medicare parts A and B by 

institutional and other providers, practitioners, and suppliers of health care items and services; 
CMS-1590-P 332 

encourage investment in administrative structures and processes to ensure efficient service 

delivery; and reward physicians for improving health outcomes and reducing the rate of growth 

in health care expenditures. In the PGP Transition demonstration, the goal of beneficiary 

assignment criteria is to identify Medicare beneficiaries that have a plurality of their allowed 

charges for office evaluation and management (E & M) services furnished at a participating PGP 

during the year. If they do not have any primary care physician visits, then they are assigned 

using plurality of allowed charges for all office E & M physician visits regardless of specialty. 

 In 2012, the beneficiaries that we assigned to group practices, for purposes of reporting 

on the PQRS quality measures via the GPRO web-interface, were limited to those Medicare Part 

B FFS beneficiaries with Medicare Parts A and B claims for whom Medicare is the primary 

payer. Assigned beneficiaries did not include Medicare Advantage enrollees. We assigned a 

beneficiary to the group practice if the practice provided the plurality of a beneficiary’s office or 

other outpatient office evaluation and management allowed charges. Beneficiaries with only one 

office visit to the group practice were eliminated from the group practice’s assigned patient 

population. Please note that, for the GPRO web-interface, similar to the PGP demonstration, 

also takes eligible professional services other than physician services when evaluating a group 

practice’s office E & M services. We are proposing to continue using this assignment 

methodology for 2013 and subsequent years because it is already in place operationally. We 

believe the assignment methodology we are currently using adequately captures sufficient data to 

reflect the quality of care furnished by group practices reporting under the GPRO web-interface. 

We invite public comment on our proposal to continue to use this methodology for assigning 

beneficiaries. 

 We note that the Medicare Shared Savings Program uses a somewhat different 

assignment methodology. More information regarding the assignment methodology that is used 
CMS-1590-P 333 

in the Shared Savings Program be found on the program website at 

https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/sharedsavingsprogram/index.html?redirect=/sharedsavingsprogram/. However, we 

note that consistent with the requirements of section 1899(c) of the Act, the assignment 

methodology used in the Shared Savings Program (which involves a 2-step process) has a greater 

focus on physician-provided primary care services. 

 In order to more closely align with the Medicare Shared Savings Program, we considered 

proposing to modify the assignment method PQRS uses to assign beneficiaries to a group 

practice to be similar to the two-step assignment method specified in §425.402 that is used under 

the Medicare Shared Savings Program to assign beneficiaries to an ACO. Consistent with that 

two-step methodology, in order for a beneficiary to be eligible for assignment to a group 

practice, the beneficiary must have received at least one primary care service from a physician 

(as defined in §425.20) within the group practice during the reporting period. Accordingly, we 

would identify beneficiaries who received at least one primary care service from any group 

practice physician (regardless of specialty) participating in the group practice during the 

reporting period. Under the first assignment step, we would assign the beneficiary to the group 

practice if the beneficiary had at least one primary care service furnished by a primary care 

physician at the participating group practice, and more primary care services (measured by 

Medicare allowed charges) furnished by primary care physicians in the participating group 

practice than furnished by primary care physicians at any other group practice or non-group 

practice physician. The second step applies only for those beneficiaries who do not receive any 

primary care services from a primary care physician during the reporting period. We would 

assign the beneficiary to the participating group practice in this step if the beneficiary had at least 

one primary care service furnished by a group practice physician, regardless of specialty, and 
CMS-1590-P 334 

more primary care services were furnished by group practice professionals (including nonprimary care physicians, nurse practitioners, physician assistants or clinical nurse specialists) 

(measured by Medicare allowed charges) at the participating group practice than at any other 

group practice or non-group practice physician. We would then pull samples of beneficiaries for 

the relevant measures/modules from this population of assigned beneficiaries to populate the 

GPRO web interface. We considered making this change to the assignment method beginning 

with the 2013 PQRS GPRO web-interface so that the rules used to assign beneficiaries to group 

practices participating in PQRS and ACOs participating in the Medicare Shared Savings 

Program would be consistent. Since both group practices that are participating in the PQRS 

GPRO and ACOs participating in the Medicare Shared Savings Program would be using the 

same GPRO web interface to report the same set of quality measures to CMS, we believe that 

applying consistent assignment methods across the two programs would allow us to streamline 

our processes and could potentially reduce confusion among group practices considering 

participation in the PQRS GPRO or ACOs considering participation in the Medicare Shared 

Savings Program. We invite public comment on this alternative option of adopting a 

methodology similar to the one the Medicare Shared Savings Program uses to assign 

beneficiaries to ACOs to assign beneficiaries to group practices that report on PQRS quality 

measures via the GPRO web-interface beginning in 2013. 

Consistent with the group practice reporting requirements under section 1848(m)(3)(C) of 

the Act, we propose the following criteria 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 incentives, respectively, using the GPRO Web-interface for 

groups practices of 25-99 eligible professionals: Report on all measures included in the web 

interface; AND populate data fields for the first 218 consecutively ranked and assigned 
CMS-1590-P 335 

beneficiaries in the order in which they appear in the group's sample for each disease module or 

preventive care measure. If the pool of eligible assigned beneficiaries is less than 218, then 

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 218 

patients on which a group practice may report, particularly those group practices on the smaller 

end of the range of 25-99 eligible professionals. If the group practice is assigned less than 218 

Medicare beneficiaries, then the group practice would report on 100 percent of its assigned 

beneficiaries. In addition, we propose the following criteria for the satisfactory reporting of 

PQRS quality measures for group practices selected to participate in the GPRO for the 2013 and 

2014 incentives, respectively, using groups practices of 100 or more eligible professionals: 

Report on all measures included in the web interface; AND populate data fields for the first 411 

consecutively ranked and assigned beneficiaries in the order in which they appear in the group's 

sample for each disease module or preventive care measure. If the pool of eligible assigned 

beneficiaries is less than 411, then report on 100 percent of assigned beneficiaries. 

The satisfactory criteria we proposed for the GPRO web-interface for large group 

practices for the 2013 and 2014 incentives is consistent with the reporting criteria we established 

for the 2012 PQRS incentive (76 FR 73339). The satisfactory criteria we proposed for groups of 

25-99 eligible professionals are consistent with the reporting criteria we established for the 2012 

PQRS incentive (76 FR 73339). We are proposing these same criteria because the thresholds 

proposed in these criteria are based on analysis performed on group reporting based on the PGP 

demonstration to determine reasonable thresholds for group practice reporting. Therefore, we 

believe the satisfactory reporting criteria that we have proposed for the GPRO web-interface for 

the 2013 and 2014 incentives are appropriate criteria and reasonable for groups to meet. 

 Furthermore, we propose using Medicare Part B claims data for dates of service on or 
CMS-1590-P 336 

after January 1 and submitted and processed by approximately the last Friday in October of the 

applicable 12-month reporting period under which the group practice participates in the GPRO to 

assign Medicare beneficiaries to each group practice. For example, for a group practice 

participating under the GPRO for the reporting periods occurring in 2013, for the sampling 

model, we propose that we would assign beneficiaries on which to report based on Medicare Part 

B claims with dates of service beginning January 1, 2013 and processed by October 25, 2013. 

We invite public comment on our proposal to continue to use this methodology for assigning 

beneficiaries. 

 (2) Proposed Criteria for Satisfactory Reporting on Individual PQRS Quality Measures for 

Group Practices Selected to Participate in the GPRO via Claims, Registry, and EHR 

 We are proposing to have the claims, registry, and EHR reporting mechanisms available 

for group practices of 2-99 eligible professionals to use to report PQRS quality measures. We 

note that we are not proposing to make the claims, registry, and EHR reporting mechanisms 

available to larger groups of 100 or more eligible professionals, because we believe that these 

larger group practices do not face the potential limitations that smaller group practices may face 

when using the GPRO web-interface. Although group practices of 100-249 were also only 

introduced to the GPRO web-interface in 2012, we note that we believe these practices are 

sufficiently large enough to account for the varied measures required for reporting under the 

GPRO web-interface. For example, the proposed criteria for satisfactory reporting on individual 

PQRS quality measures for group practices using the GPRO web-interface would require a group 

practice to report on all 18 measures that are indicated in Table 35. Larger group practices tend 

to have more varied practices, so it would be easier for larger groups to report on a measure set 

that covers multiple domains, such as the one proposed in Table 35, than smaller group practices 

that tend to be focused on a limited set of specialties. We certainly think this is the case for the 
CMS-1590-P 337 

smallest group practices comprised of 2-24 eligible professionals, which is the reason why we 

are not proposing that the GPRO web-interface be available for use for these smaller group 

practices. With respect to group practices comprised of 25-99 eligible professionals, we believe 

it is possible for these group practices to have a practice that is sufficiently varied to be able to 

report on measures that cut across multiple domains. However, we note that use of the GPRO 

web-interface as a reporting mechanism was only introduced to groups of 2-99 in 2012, so no 

data is available to determine the feasibility of groups of 25-99 using the GPRO web-interface. 

Therefore, in the event these groups feel that reporting using the GPRO web-interface would be 

difficult, we are proposing criteria alternative to that proposed under the GPRO web-interface for 

satisfactory reporting for the 2013 and 2014 incentives using the claims, registry, and EHRbased reporting mechanisms that mirror the criteria we are proposing for individual reporting for 

the claims, registry, and EHR-based reporting mechanisms from the 2013 and 2014 incentives. 

We note that the criteria we are proposing for the 2013 and 2014 incentives using the claims, 

registry, and EHR-based reporting mechanisms are similar to the criteria for individual reporting, 

because we believe smaller group practices are more akin to individuals with respect to practice 

scope. The larger the group practice, the more likely the group practice would benefit using the 

reporting options under the GPRO web-interface. 

 Therefore, based on our authority under section 1848(m)(3)(C) of the Act, we propose 

the following satisfactory reporting criteria via claims for group practices comprised of 2-99 

eligible professionals under the GPRO for the 2013 and 2014 incentives via claims: Report at 

least 3 measures 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 zero percent performance rate will not be counted. 

For those group practices that choose to report using a qualified registry, we propose the 
CMS-1590-P 338 

following satisfactory reporting criteria via qualified registry for group practices comprised of 2-

99 eligible professionals under the GPRO for the 2013 and 2014 incentives: Report at least 3 

measures AND report each measure for at least 80 percent of the group practice's Medicare Part 

B FFS patients seen during the reporting period to which the measure applies. Measures with a 

zero percent performance rate will not be counted. Please note that we are only proposing these 

satisfactory reporting criteria for group practices comprised of 2-99 eligible professionals 

because we believe that larger group practices should have the technical capacity and resources 

to report on the more expansive measure set that is collected via the GPRO web-interface. 

For group practices choosing to report PQRS quality measures via EHR, we propose the 

following 2 options for the satisfactory reporting criteria via a direct EHR product or EHR data 

submission vendor for group practices comprised of 2-99 eligible professionals under the GPRO 

for the 2013 incentive: 

 Option 1: Eligible professionals in a group practice must report on three Medicare EHR 

Incentive Program core or alternate core measures, plus three additional measures. The EHR 

Incentive Program’ core, alternate core, and additional measures can be found in Table 6 of the 

EHR Incentive Program’s Stage 1 final rule (75 FR 44398) or in Tables 32 and 33 of this section. 

We refer readers to the discussion in the Stage 1 final rule for further explanation of the 

requirements for eligible professionals reporting those CQMs (75 FR 44398 through 44411). 

Option 2: Report at least 3 measures AND report each measure for at least 80 percent of 

the eligible professional’s Medicare Part B FFS patients seen during the reporting period to 

which the measure applies. Measures with a zero percent performance rate will not be counted. 

 We note that the Medicare EHR Incentive Program has proposed 2 options for meeting 

the CQM component of achieving meaningful use beginning with CY 2014 (for more 

information on these options, please see 77 FR 13746—13748). To align our EHR-based 
CMS-1590-P 339 

reporting requirements with those proposed under the Medicare EHR Incentive Program, we are 

proposing the following criteria for satisfactory reporting using the EHR-based reporting 

mechanism for the 12-month reporting period for the 2014 incentive: 

● Option 1a: Select and submit 12 clinical quality measures available for EHR-based 

reporting from Tables 32 and 33, including at least 1 measure from each of the following 6 

domains – (1) patient and family engagement, (2) patient safety, (3) care coordination, (4) 

population and public health, (5) efficient use of healthcare resources, and (6) clinical 

process/effectiveness. 

● Option 1b: Submit 12 clinical quality measures composed of all 11 of the proposed 

Medicare EHR Incentive Program core clinical quality measures specified in Tables 32 and 33 

plus 1 menu clinical quality measure from Tables 32 and 33. We propose to adopt the group 

reporting criteria that aligns with the criteria that will be established for meeting the CQM 

component under CY 2014 for the Medicare EHR Incentive Program. Furthermore, to the extent 

that the final group reporting criteria for meeting the CQM component of achieving meaningful 

use differ from what was proposed, our intention is to align with the group reporting criteria the 

EHR Incentive Program ultimately establishes. We invite public comment on this proposal. 

We also considered proposing the following satisfactory reporting criteria for the 2014 

PQRS incentive for groups of 2-99 that was similar to the satisfactory reporting criteria being 

proposed for the 2013 PQRS incentive: report at least 3 measures, AND report each measure for 

at least 80 percent of the group practice’s Medicare Part B FFS patients seen during the reporting 

period to which the measure applies. Measures with a zero percent performance rate will not be 

counted. We invite public comment on this considered proposal. 

We note that we believe these proposed criteria meets the requirements for group practice 

reporting specified in section 1848(m)(3)(C) of the Act. Section 1848(m)(3)(C) requires that the 
CMS-1590-P 340 

criterion for group reporting use a statistical sampling model, such as the model used in the PGP 

demonstration. We note that, although these criteria depart from the model used in the PGP 

demonstration, we believe that these criteria still meet the statistical sampling model requirement 

in that the group practices would still be required to report the measures on a sample of their 

patients. Rather than CMS choosing which sample of patients the group practice must report, 

with these proposed criteria, the group practice decides on which sample of patients to report for 

either 50 percent, 80 percent, or 100 percent of its patients depending on the reporting 

mechanism the group practice chooses. For example, if a group practice who sees 100 patients 

during the 2013 incentive reporting period chooses to report PQRS quality measures using the 

claims-based reporting mechanism, for the 2013 incentive, the group practice would have to 

report at least 3 measures for 50 percent of the practice’s patients. The group practice may pick 

which patients on which to report, as long as the group practice reports on at least 50 of the 

patients the practice sees in 2013. If the same group practice decides to report on PQRS quality 

measures using the Option 1 criteria for EHR-based reporting for the 2013 incentive, the group 

practice would report on all 100 patients. We note that although reporting on 100 percent of 

patients is not a sample, for data collection purposes, CMS would only collect data on the group 

practice’s patients to which the EHR measures apply. Therefore, even though a group practice 

would report on 100 percent of patients to which the measure applies, not all of the EHR 

measures would necessarily apply to all of the group practice’s patients. Since the group practice 

is then only providing information on its applicable patients, we believe the proposed EHR 

reporting criteria would still meet the statistical sampling model requirement. We invite public 

comment on the proposed criteria for satisfactory reporting of individual measures by group 

practices via claims, registry, or EHR for the 2013 and 2014 incentives. 

A summary of the proposed criteria for satisfactory reporting for group practices selected 
CMS-1590-P 341 

to participate in the GPRO for the 2013 and 2014 incentives is specified in Tables 27 and 28: 

TABLE 27: Proposed Criteria for Satisfactory Reporting of Data on PQRS Quality 

Measures via the GPRO for the 2013 Incentive 

Reporting 

Period 

Reporting 

Mechanism 

Group 

Practice Size Proposed Reporting Criterion 

12-month 

(Jan 1 — 

Dec 31) 

GPRO WebInterface 25-99 eligible 

professionals 

Report on all measures included in the web interface in Table 

35; AND 

Populate data fields for the first 218 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 218, then 

report on 100 percent of assigned beneficiaries. 

12-month 

(Jan 1 — 

Dec 31) 

GPRO WebInterface 100+ eligible 

professionals 

Report on all measures included in the web interface in Table 

35; AND 

Populate data fields for the first 411 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 411, then 

report on 100 percent of assigned beneficiaries. 

12-month 

(Jan 1 — 

Dec 31)* 

Claims 2-99 eligible 

professionals 

Report at least 3 measures, 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 will not be counted. 

12-month 

(Jan 1 — 

Dec 31) 

Qualified 

Registry 

2-99 eligible 

professionals 

Report at least 3 measures, AND 

Report each measure for at least 80 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 will not be counted. 

12-month 

(Jan 1 — 

Dec 31) 

Direct EHR 

product 

2-99 eligible 

professionals 

Option 1: Eligible professionals in a group practice must report 

on three Medicare EHR Incentive Program core or alternate core 

measures, plus three additional measures. The EHR Incentive 

Program’ core, alternate core, and additional measures can be 

found in Table 6 of the EHR Incentive Program’s Stage 1 final 

rule (75 FR 44398) or in Tables 32 and 33 of this section. We 

refer readers to the discussion in the Stage 1 final rule for further 

explanation of the requirements for eligible professionals for 

reporting those CQMs (75 FR 44398 through 44411). 

Option 2: Report at least 3 measures, AND 

Report each measure for at least 80 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 will not be counted. 

12-month 

(Jan 1 — 

Dec 31) 

EHR data 

submission 

vendor 

2-99 eligible 

professionals 

Option 1: Eligible professionals in a group practice must report 

on three Medicare EHR Incentive Program core or alternate core 

measures, plus three additional measures. The EHR Incentive 

Program’ core, alternate core, and additional measures can be 

found in Table 6 of the EHR Incentive Program’s Stage 1 final 

rule (75 FR 44398) or in Tables 32 and 33 of this section. We 

refer readers to the discussion in the Stage 1 final rule for further 

explanation of the requirements for eligible professionals for 

reporting those CQMs (75 FR 44398 through 44411). 

Option 2: Report at least 3 measures, AND 

Report each measure for at least 80 percent of the group 

practice’s Medicare Part B FFS patients seen during the 
CMS-1590-P 342 

Reporting 

Period 

Reporting 

Mechanism 

Group 

Practice Size Proposed Reporting Criterion 

reporting period to which the measure applies. 

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

* Subject to the measure applicability validation (MAV) process. 

Table 28: Proposed Criteria for Satisfactory Reporting of Data on PQRS Quality 

Measures via the GPRO for the 2014 Incentive 

Reporting 

Period 

Reporting 

Mechanism 

Group Practice 

Size Proposed Reporting Criterion 

12-month 

(Jan 1 — 

Dec 31) 

GPRO 

WebInterface 

25-99 eligible 

professionals 

Report on all measures included in the web interface in Table 35; 

AND 

Populate data fields for the first 218 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 218, then report 

on 100 percent of assigned beneficiaries. 

12-month 

(Jan 1 — 

Dec 31) 

GPRO 

WebInterface 

100+ eligible 

professionals 

Report on all measures included in the web interface in Table 35; 

AND 

Populate data fields for the first 411 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 411, then report 

on 100 percent of assigned beneficiaries. 

12-month 

(Jan 1 — 

Dec 31)* 

Claims 2-99 eligible 

professionals 

Report at least 3 measures, 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 will not be counted. 

12-month 

(Jan 1 — 

Dec 31) 

Qualified 

Registry 

2-99 eligible 

professionals 

Report at least 3 measures, AND 

Report each measure for at least 80 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 will not be counted. 

12-month 

(Jan 1 — 

Dec 31) 

Direct EHR 

product 

2-99 eligible 

professionals 

Option 1a: Select and submit 12 clinical quality measures available 

for EHR-based reporting from Tables 32 and 33, including at least 

1 measure from each of the following 6 domains – (1) patient and 

family engagement, (2) patient safety, (3) care coordination, (4) 

population and public health, (5) efficient use of healthcare 

resources, and (6) clinical process/effectiveness. 

Option 1b: Submit 12 clinical quality measures composed of all 11 

of the proposed Medicare EHR Incentive Program core clinical 

quality measures specified in Tables 32 and 33 plus 1 menu 

clinical quality measure from Tables 32 and 33. 

Option 2: Report at least 3 measures, AND 

Report each measure for at least 80 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 will not be counted. 

12-month 

(Jan 1 — 

Dec 31) 

EHR data 

submission 

vendor 

2-99 eligible 

professionals 

Option 1a: Select and submit 12 clinical quality measures available 

for EHR-based reporting from Tables 32 and 33, including at least 

1 measure from each of the following 6 domains – (1) patient and 

family engagement, (2) patient safety, (3) care coordination, (4) 

population and public health, (5) efficient use of healthcare 

resources, and (6) clinical process/effectiveness. 
CMS-1590-P 343 

Reporting 

Period 

Reporting 

Mechanism 

Group Practice 

Size Proposed Reporting Criterion 

Option 1b: Submit 12 clinical quality measures composed of all 11 

of the proposed Medicare EHR Incentive Program core clinical 

quality measures specified in Tables 32 and 33 plus 1 menu 

clinical quality measure from Tables 32 and 33. 

Option 2: Report at least 3 measures, AND 

Report each measure for at least 80 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 will not be counted. 

* Subject to the measure applicability validation (MAV) process. 

c. Proposed Analysis of the Criteria for Satisfactory Reporting for the 2013 and 2014 Incentives 

For the proposed criteria for satisfactory reporting for the 2013 and 2014 incentives 

described in this section, we propose that eligible professionals and group practices may not 

combine different satisfactory reporting criteria under different reporting mechanisms to meet 

the requirements of satisfactory reporting for the 2013 and 2014 incentives. For example, an 

eligible professional may not meet the requirements for the 2013 incentive by reporting on 2 

applicable PQRS quality measures via claims and 1 applicable PQRS quality measure via 

qualified registry, because the eligible professional did not meet the criteria for satisfactory 

reporting under at least one reporting mechanism. Similarly, a group practice would be required 

to select a single reporting mechanism for the entire group practice. For example, for a group 

practice consisting of 4 eligible professionals, the group practice would not be able to meet the 

requirements for the 2013 incentive by reporting 2 individual measures via claims and 1 measure 

via the direct EHR submission method. 

For individual eligible professionals and group practices reporting on individual measures 

and/or measures groups, please note that, although an eligible professional or group practice 

could meet more than one criterion for satisfactory reporting, only one incentive payment will be 

made to the eligible professional or group practice. For example, if an eligible professional 

meets the criteria for satisfactory reporting of individual measures via claims and measures 
CMS-1590-P 344 

groups via claims for the 2013 incentive, the eligible professional would nonetheless only be 

entitled to one incentive payment. CMS would consider the eligible professional to be incentive 

eligible under whichever reporting criterion yields the greatest bonus. We invite public comment 

on our proposed analysis of the criteria for satisfactory reporting for the 2013 and 2014 

incentives. 

5. Proposed Criteria for Satisfactory Reporting for the Payment Adjustments 

Section 1848(a)(8) of the Social Security 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 shall be equal to the applicable percent of the fee schedule amount that would 

otherwise apply to such services. The applicable percent for 2015 is 98.5 percent. For 2016 and 

subsequent years, the applicable percent is 98.0 percent. 

This section contains the proposed criteria for satisfactory reporting for purposes of the 

2015 and 2016 payment adjustments for eligible professionals and group practices, as well as 

some discussion of what we are considering for the payment adjustments for 2017 and beyond. 

 As stated previously, the majority of eligible professionals currently are not participating 

in the PQRS. Yet, the payment adjustment will apply to all eligible professionals who are not 

satisfactory reporters during the reporting period for the year. Therefore, in implementing the 

PQRS payment adjustment, we seek to achieve two overarching policy goals. First, and 

foremost, we seek to increase participation in the PQRS and to implement the payment 

adjustment in a manner that will allow eligible professionals who have never participated in the 

program to familiarize themselves with the program. Second, we seek to align the reporting 
CMS-1590-P 345 

requirements under the PQRS with the quality reporting requirements being proposed for the 

physician value-based payment modifier discussed in section III.K of this proposed rule. 

a. Proposed Criteria for Satisfactory Reporting for the 2015 and 2016 Payment Adjustments for 

Eligible Professionals and Group Practices using the Claims, Registry, EHR, and GPRO webinterface Reporting Mechanisms 

 This section contains our proposals for the criteria for satisfactory reporting for the 2015 

and 2016 payment adjustments using the claims, registry, EHR-based, and GPRO web-interface 

reporting mechanisms. First, we propose that for purposes of the 2015 and 2016 payment 

adjustments (which would be based on data reported during 12 and 6-month reporting periods 

that fall within 2013 and 2014, respectively), an eligible professional or group practice would 

meet the requirement to satisfactorily report data on quality measures for covered professional 

services for the 2015 and 2016 payment adjustments by meeting the requirement for satisfactory 

reporting for the 2013 and 2014 incentives respectively. That is, we are proposing the exact 

same criteria for satisfactory reporting for the 2015 and 2016 payment adjustments that we are 

proposing for the 2013 and2014 incentives, described in Tables 25 and 26, with the exception of 

one additional alternative criterion. Since we have already proposed satisfactory reporting 

criteria for the 2013 and 2014 incentives and the reporting periods for the respective 2013 and 

2014 incentives and 2015 and 2016 payment adjustments coincide, we believe it is appropriate 

that the proposed criteria for the 2013 and 2014 respective incentives apply to satisfy the 

satisfactory reporting requirements for the 2015 and 2016 payment adjustments, respectively. 

Please note that these proposed criteria for the 2013 and 2014 PQRS incentives are the only 

criteria we are proposing to establish for the respective 2015 and 2016 PQRS payment 

adjustments for group practices using the GPRO web-interface. 

 With respect to individual eligible professionals also participating in the EHR Incentive 
CMS-1590-P 346 

Program, it is our intention to align our proposed criteria for satisfactory reporting for the 2015 

and 2016 PQRS payment adjustments with the criteria for meeting the CQM component of 

meaningful use applicable during the 2015 and 2016 PQRS payment adjustment reporting 

periods. For eligible professionals participating in PQRS and the EHR Incentive Program using 

a direct EHR product or EHR data submission vendor that is CEHRT, please note that since we 

are proposing to align our proposed EHR criteria for satisfactory reporting for the 2013 and 2014 

PQRS incentives with the proposed criteria for meeting the CQM component of meaningful use 

for CYs 2013 and 2014,if these proposals are established and we meet our goal of aligning the 

two programs, we note that an eligible professional meeting the CQM component of meaningful 

use during the PQRS 2015 and 2016 payment adjustment reporting periods using a direct EHR 

product or EHR data submission vendor that is CEHRT would be able to meet the requirements 

for satisfactory reporting for the 2015 and 2016 PQRS payment adjustments by submitting a 

single set of data. 

 As a result of the overarching goals we have articulated above about encouraging 

participation and concern about eligible professionals’ familiarity and experience with the 

program, we propose the following alternative criteria for satisfactory reporting during the 12-

month reporting periods for the 2015 and 2016 payment adjustments for eligible professionals 

and group practices: report 1 measure or measures group using the claims, registry, or EHRbased reporting mechanisms. We understand that this particular proposed alternative criterion 

for satisfactory reporting are significantly less stringent that the satisfactory reporting criteria we 

have proposed for the 2013 and 2014 incentives. However, we stress that we are proposing less 

stringent criteria only to ease eligible professionals and group practices who have not previously 

participated in PQRS into reporting. We note that we are only proposing these criteria for the 

2015 and 2016 payment adjustments. As indicated in section III.G.5.c., for 2017 and beyond, we 
CMS-1590-P 347 

anticipate eliminating these alternative proposed criteria and establishing criteria that more 

closely resembles the proposed satisfactory reporting criteria for the 2013 and 2014 incentives. 

 With respect to group practices, section 1848(m)(3)(C) requires that the criterion for 

group reporting use a statistical sampling model, such as the model used in the PGP 

demonstration, we note that this proposed reporting criteria meets this standard, as the group 

practice would decide on which sample of patients to report. In these proposed criteria, the 

group practice would select the sample number, meaning the group could choose to report on all 

applicable patients or a certain number of patients to which the particular measure applied. 

Please note that, although the group practice may choose the sample, we anticipate that the 

sample the group practice selects would represent a sufficient picture of the beneficiaries the 

group practice sees. We invite public comment on the proposed criteria for satisfactory reporting 

for the 2015 and 2016 payment adjustments for eligible professionals and group practices using 

the claims, registry, EHR-based reporting mechanisms. 

b. Proposed Criteria for Satisfactory Reporting for the 2015 and 2016 Payment Adjustments for 

Eligible Professionals and Group Practices using the Administrative Claims-based Reporting 

Mechanism 

(1) Proposed Criteria for Satisfactory Reporting for the 2015 and 2016 Payment Adjustments for 

Eligible Professionals and Group Practices using the Administrative Claims-based Reporting 

Mechanism 

 Unlike the traditional PQRS claims-based reporting mechanism, the proposed 

administrative claims-based reporting mechanism does not require an eligible professional to 

submit quality data codes (QDCs) on Medicare Part B claims. Rather, using the administrative 

claims-based reporting mechanism only requires that an eligible professional or group practice 

submit Medicare claims to CMS. Since CMS, rather than the eligible professional or group 
CMS-1590-P 348 

practice, is performing the analysis and collecting the data provided in an eligible professional’s 

or group practice’s Medicare claims for an eligible professional’s or group practice’s Medicare 

beneficiaries, we believe it is appropriate to propose a reporting threshold that is more stringent 

than that proposed for the 2013 and 2014 incentives that use traditional PQRS reporting 

mechanisms. Therefore, we propose the following criteria for satisfactory reporting for the 12-

month reporting periods for the 2015 and 2016 payment adjustments for eligible professionals 

and group practices using the administrative claims-based reporting mechanism: Report ALL 

measures in Table 63 for 100 percent of the cases in which the measures apply. 

 Section 1848(m)(3)(C) requires that the criterion for group reporting use a statistical 

sampling model, such as the model used in the PGP demonstration. We note that, although these 

criteria depart from the model used in the PGP demonstration, similar to our arguments for the 

satisfactory reporting criteria we are proposing for group practices using the claims, registry, and 

EHR-based reporting mechanisms, we believe that these criteria still meet the statistical 

sampling model requirement in that the group practices would still be required to report the 

measures on a sample of their patients. We understand that, with these proposed criteria, the 

group practice provides claims data to CMS on 100 percent of its patients for which the measure 

applies. We note that although reporting on 100 percent of patients is not a sample, for data 

collection purposes, CMS would only collect data on the group practice’s patients to which the 

administrative claims measures apply. Therefore, even though a group practice who sees 100 

patients during the applicable PQRS payment adjustment reporting period would report on 100 

percent of patients to which the measure applies, not all of the proposed administrative claims 

measures would necessarily apply to all of the group practice’s patients. Since the group practice 

is then only providing information on its applicable patients, we believe these reporting criteria 

would still meet the statistical sampling model requirement. We invite public comment on these 
CMS-1590-P 349 

proposed criteria. 

 When considering proposals for reporting criteria for the 2015 and 2016 PQRS payment 

adjustments, we considered satisfactory reporting options that would encourage eligible 

professionals and group practices to report for the 2013 and/or 2014 incentives but, should 

eligible professionals or group practices come up shy of meeting the 2013 and/or 2014 incentive 

reporting criteria, would still allow an eligible professional to meet the criteria for satisfactory 

reporting for the 2015 and/or 2016 payment adjustments. In lieu or more lenient satisfactory 

reporting criteria we proposed for the 2015 and 2016 payment adjustment, e.g. to report at least 1 

measure or measures group or to elect the administrative claims-based reporting option, we 

considered the option of defaulting those eligible professionals who report but fail to meet the 

criteria for satisfactory reporting using the proposed criteria for the 2013 and/or 2014 incentives 

to the administrative claims-based reporting option. We would therefore analyze the claims of 

all eligible professionals who report at least 1 measure under a traditional reporting method 

during the respective 2015 and 2016 payment adjustment reporting periods under the 

administrative claims-based reporting option. We considered this proposal because it is our 

intention to encourage eligible professionals to report PQRS measures using the proposed 

reporting criteria for the 2013 and 2014 PQRS incentives. However, given our concern about 

new eligible professionals’ familiarity and experience with the program, we believe it is 

necessary to propose an alternative, less stringent reporting option. We invite public comment 

on this considered proposal. 

c. Proposed Analysis of Eligible Professionals and Group Practices who will be Assessed a 

PQRS Payment Adjustment 

 As noted in §414.90(b), an eligible professional is assessed at the TIN/NPI level and a 

group practice selected to participate in the GPRO is assessed at the TIN level. As there is a 1-
CMS-1590-P 350 

year lapse in time between the end of a proposed respective payment adjustment reporting period 

and when an eligible professional is expected to receive a PQRS payment adjustment for not 

meeting the requirements for satisfactory reporting for the respective payment adjustment, we 

understand that an eligible professional may change his or her TIN/NPIs during this lapse of 

time. Likewise, a group practice selected to participate in the GPRO may change its TIN during 

this lapse in time. We believe this raises issues with regard to the subsequent application of the 

payment adjustment and concerns about the potential for abuse (e.g., “gaming the system”). 

Accordingly, we invite public comment this issue, including what parameters, if any, CMS 

should impose regarding the changes in TIN/NPIs and compositions of group practices with 

regard to the payment adjustment. 

d. Criteria for Satisfactory Reporting for the Payment Adjustments for 2017 and Beyond for 

Eligible Professionals and Group Practices 

 We have stressed the importance of allowing eligible professionals and group practices 

who are new to the program to gain familiarity with PQRS’s reporting requirements. However, 

we note that, as we move towards the sole implementation of payment adjustments (which would 

serve as the reporting period for the 2017 payment adjustment), it is our intention that eligible 

professionals would be expected to meet reporting criteria that more closely align to the 

reporting criteria that we have proposed for the 2014 incentives above. It is our expectation that 

in two years' time, eligible professionals who are new to PQRS would have enough familiarity 

with the program that CMS could reasonably expect a majority of participating eligible 

professionals to meet the requirements that are identical or very similar to those that have been 

required for incentive payment purposes. We invite public comment on goals for future criteria 

for satisfactory reporting we may require under the program for the 2017 payment adjustment 

that are identical or similar to the criteria we have proposed for the 2014 incentive payments. 
CMS-1590-P 351 

We also invite commenters to provide alternative criteria for us to consider in future rulemaking 

for the payment adjustments for 2017 and beyond. 

6. PQRS Quality Measures for 2013 and Beyond 

a. Statutory Requirements for the Selection of Proposed PQRS quality measures for 2013 and 

Beyond 

Under section 1848(k)(2)(C)(i) of the Act, the PQRS quality measures shall be such 

measures selected by the Secretary from measures that have been endorsed by the entity with a 

contract with the Secretary under subsection 1890(a) of the Act (currently, that is the National 

Quality Forum, or 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 AQA alliance. 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) (that is, the 

NQF) and are silent for how the measures that are submitted to the NQF for endorsement were 

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 
CMS-1590-P 352 

variety of different organizations. We do not believe there needs to be any 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, as amended by 

adding section 3014 of the Patient Protection and Affordable Care Act (PPACA), requires that 

the entity with a contract with the Secretary under subsection 1890(a) of the Act (currently that, 

is the NQF) establish a multi-stakeholder group that would provide for a transparent process for 

selecting quality measures, such as the quality measures selected for reporting under the PQRS. 

Pursuant to section 3014 of Affordable Care Act, the NQF created the Measure Applications 

Partnership. Section 1890(b)(7)(B) requires that the Secretary establish a pre-rulemaking 

process whereby the multi-stakeholder group will provide input to the Secretary on the selection 

of quality measures. To receive input from the Measures Applications Partnership, we submitted 

all the measures we are proposing in this section with the exception of the administrative claims 

measures that we are incorporating to align with the Value-Based Modifier and the measures that 

we are incorporating to align with the Medicare Shared Savings Program specified in Tables 29 

through 62. The list of measures the Measures Application Partnership have considered for 2012 

are available at 

http://www.qualityforum.org/Setting_Priorities/Partnership/Measure_Applications_Partnership.a

spx. 

b. Other Considerations for the Selection of Proposed PQRS quality measures for 2013 and 

Beyond 
CMS-1590-P 353 

 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. 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: 

● High impact on healthcare. 

● Measures that are high impact and support CMS and HHS priorities for improved 

quality and efficiency of care for Medicare beneficiaries. 

● Measures that address gaps in the quality of care delivered to Medicare beneficiaries. 

● Address Gaps in the PQRS measure set. 

● Measures impacting chronic conditions (chronic kidney disease, diabetes mellitus, 

heart failure, hypertension and musculoskeletal). 

● Measures applicable across care settings (such as, outpatient, nursing facilities, 

domiciliary, etc.). 

● Broadly applicable measures that could be used to create a core measure set required 

of all participating eligible professionals. 

● Measures groups that reflect the services furnished to beneficiaries by a particular 

specialty. 

On October 7, 2011, we ended a Call for Measures that solicited new measures for 

possible inclusion in the PQRS for 2013 and beyond. During the Call for Measures, we 

solicited measures that were either consistent with section 1848(k)(2)(C) of the Act or fell under 

the exception specified in section 1848(k)(2)(C)(ii) of the Act. Although the deadline to submit 
CMS-1590-P 354 

measures for consideration for the 2013 PQRS program year has ended, we invite public 

comment on future considerations related to the selection of new PQRS quality measures. 

c. Proposed PQRS Quality Measures 

This section focuses on the proposed PQRS individual Measures available for reporting 

via claims, registry, and/or EHR-based reporting for 2013 and beyond. To align with the 

proposed measure domains provided in the EHR Incentive Program (77 FR 13743), we classify 

all proposed measures against six domains based on the National Quality Strategy’s six 

priorities, as follows: 

 (1) Patient and Family Engagement. 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 through greater involvement of patients and families 

in decision making, self care, activation, and understanding of their health condition and its 

effective management. 

 (2) Patient Safety. These are measures that reflect the safe delivery of clinical services in 

both hospital and ambulatory settings and include processes that would reduce harm to patients 

and reduce burden of illness. These measures should enable longitudinal assessment of 

condition-specific, patient-focused episodes of care. 

 (3) 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 in order to improve 

appropriate and timely patient and care team communication. 

(4) Population and Public Health. These are measures that reflect the use of clinical and 

preventive services and achieve improvements in the health of the population served and are 
CMS-1590-P 355 

especially focused on the leading causes of mortality. These are outcome-focused and have the 

ability to achieve longitudinal measurement that will demonstrate improvement or lack of 

improvement in the health of the US population. 

(5) Efficient Use of Healthcare Resources. These are measures that reflect efforts to 

significantly improve outcomes and reduce errors. These measures also impact and benefit a 

large number of patients and emphasize the use of evidence to best manage high priority 

conditions and determine appropriate use of healthcare resources. 

 (6) Clinical Processes/Effectiveness. These are measures that reflect clinical care 

processes closely linked to outcomes based on evidence and practice guidelines. 

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 2012, 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 were proposed 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 intend to 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 substantially change the nature of the 
CMS-1590-P 356 

measure. Examples of such changes could be updated diagnosis or procedure codes, changes to 

exclusions to the patient population, definitions, or extension of the measure endorsement to 

apply to other settings. We believe these types of maintenance changes are distinct from more 

substantive changes to measures that result in what are considered new or different measures, 

and that they do not trigger the same agency obligations under the Administrative Procedure 

Act. In this proposed rule, we are proposing that if the NQF updates an endorsed measure that 

we have adopted for the PQRS in a manner that we consider to not substantially 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. Specifically, we would revise the 

Specifications Manual so that it clearly identifies the updates and provide links to where 

additional information on the updates can be found. We would also post the updates on the CMS 

QualityNet Website at https://www.QualityNet.org. We would provide sufficient lead time for 

[insert applicable party; i.e. hospitals, LTCHs, etc.] to implement the changes where changes to 

the data collection systems would be necessary. 

We would continue to use the rulemaking process to adopt changes to measures that we 

consider to substantially change the nature of the measure. We believe that this proposal 

adequately balances our need to incorporate NQF updates to NQF – endorsed [insert name of 

applicable program] 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 invite public comment on 

this proposal. 

To receive more information on the proposed measures contained in this section, 

including the measure specifications for these proposed measures, please contact the respective 

measure owners. Contact information for the measure owners of these proposed PQRS measures 
CMS-1590-P 357 

is available at the PQRS Website at http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/PQRS/index.html. 

(1) Proposed PQRS Individual Core Measures Available for Claims, Qualified Registry, and 

EHR-based Reporting for 2013 and Beyond 

In 2011, the Department of Health and Human Services (HHS) started the Million Hearts 

Initiative, which is an initiative to prevent 1 million heart attacks and strokes in five years. We 

are dedicated to this initiative and seek to encourage eligible professionals to join in this 

endeavor. Therefore, based on our desire to support the Million Hearts initiative and maintain 

our focus on cardiovascular disease prevention, we are proposing the following proposed 

individual PQRS Core Measures specified in Table 29 for 2013 and beyond. Please note that 

these measures are the same measures we finalized under the 2012 PQRS in the CY 2012 

Medicare PFS final rule (76 FR 73345). 

TABLE 29: Proposed PQRS Individual Core Measures for 2013 and Beyond 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-Selected GPRO (web interface)* Measures Groups Other Quality Reporting Programs 

0064/

2 

 Clinical 

Process/ 

Effectiven

ess 

Diabetes Mellitus: Low Density 

Lipoprotein (LDL-C) Control in 

Diabetes Mellitus: Percentage of 

patients aged 18 through 75 years 

with diabetes mellitus who had 

most recent LDL-C level in control 

(less than 100 mg/dL) 

NCQA X X X X HITECH 

Million 

Hearts 

0068/

204 

 Clinical 

Process/ 

Effectiven

ess 

Ischemic Vascular Disease (IVD): 

Use of Aspirin or Another 

Antithrombotic: Percentage of 

patients aged 18 years and older 

NCQA X X X X X HITECH 

ACO 

Million 

Hearts 
CMS-1590-P 358 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-Selected GPRO (web interface)* Measures Groups Other Quality Reporting Programs 

with ischemic vascular disease 

(IVD) with documented use of 

aspirin or other antithrombotic 

0028/

226 

 Population

/Public 

Health 

Preventive Care and Screening: 

Tobacco Use: Screening and 

Cessation Intervention: 

Percentage of patients aged 18 

years and older who were screened 

for tobacco use one or more times 

within 24 months AND who 

received cessation counseling 

intervention if identified as a 

tobacco user 

AMAPCPI X X X X X HITECH 

ACO 

Million 

Hearts 

0018/

236 

 Clinical 

Process/ 

Effectiven

ess 

Hypertension (HTN): Controlling 

High Blood Pressure: Percentage 

of patients aged 18 through 85 

years of age who had a diagnosis of 

hypertension (HTN) and whose BP 

was adequately controlled (< 

140/90 mmHg) 

NCQA X X X X X HITECH 

ACO 

Million 

Hearts 

0075/

241 

 Clinical 

Process/ 

Effectiven

ess 

Ischemic Vascular Disease (IVD): 

Complete Lipid Panel and Low 

Density Lipoprotein (LDL-C) 

Control: Percentage of patients 

aged 18 years and older with 

Ischemic Vascular Disease (IVD) 

who received at least one lipid 

profile within 12 months and whose 

most recent LDL-C level was in 

control (less than 100 mg/dL) 

NCQA X X X X X HITECH 

ACO 

Million 

Hearts 

N/A/ 

316 

 Clinical 

Process/ 

Effectiven

ess 

Preventive Care and Screening: 

Cholesterol – Fasting Low 

Density Lipoprotein (LDL) Test 

Performed AND Risk-Stratified 

Fasting LDL: Percentage of 

patients aged 20 through 79 years 

CMS/

QIP 

 X HITECH 

Million 

Hearts 
CMS-1590-P 359 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-Selected GPRO (web interface)* Measures Groups Other Quality Reporting Programs 

whose risk factors* have been 

assessed and a fasting LDL test has 

been performed 

*There are three criteria for this 

measure based on the patient’s risk 

category. 

1. Highest Level of Risk: Coronary 

Heart Disease (CHD) or CHD Risk 

Equivalent 

2. Moderate Level of Risk: 

Multiple (2+) Risk Factors 

3. Lowest Level of Risk: 0 or 1 

Risk Factor 

N/A/ 

317 

 Population

/Public 

Health 

Preventive Care and Screening: 

Screening for High Blood 

Pressure: Percentage of patients 

aged 18 and older who are screened 

for high blood pressure 

CMS/

QIP 

X X X X X HITECH 

ACO 

Million 

Hearts 

*Measures that can be reported using the GPRO web interface. 

¥ Titles and descriptions in this table are aligned with the proposed 2013 Physician Quality Reporting System 

Electronic Health Records (EHR) measure titles, and may differ from existing measures in other programs. Please 

reference the National Quality Forum (NQF) and Physician Quality Reporting System numbers for clarification. 

Please note that, although we are proposing that the measures in Table 29 serve as core 

PQRS quality measures, we are not proposing to require that eligible professionals report on 

these proposed PQRS core measures. We invite public comment on the proposed PQRS core 

measures for 2013 and beyond. 

(2) Proposed PQRS quality measures Available for Reporting via the Claims, Qualified Registry, 

EHR, and GPRO Web-Interface Reporting Mechanisms for 2013 and Beyond 
CMS-1590-P 360 

This section contains our proposals for individual PQRS quality measures for 2013 and 

beyond. Please note that, in large part, we are proposing to retain most of the quality measures 

we finalized for reporting for the 2012 PQRS (76 FR 42865 through 42872). However, in 2013 

and 2014, we are proposing to include new measures, as well as remove measures that were 

available for reporting under the 2012 PQRS (not re-propose certain measures for 2013 and 

beyond). Table 30 specifies the measures we are proposing to be available for reporting under 

the PQRS for 2013 and beyond. 

TABLE 30: Proposed PQRS Individual Quality Measures Available for Reporting via 

Claims, Registry, EHR and/or the GPRO Web-Interface for 2013 and Beyond That Were 

NOT Available for Reporting under the 2012 PQRS

Reporting 

Mechanism 

NQF/ PQRS 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-Selected GPRO (web interface)* Measures Groups 

Other Quality Reporting Programs 

TBD

/ 

TBD 

Clinical 

Process/ 

Effective

ness 

Stroke and Stroke Rehabilitation: 

Tissue Plasminogen Activator (tPA) Considered (Paired Measure): 

Percentage of patients aged 18 years 

and older with a diagnosis of 

ischemic stroke who arrive at the 

hospital within 4.5 hours of time last 

known well who were considered for 

t-PA administration

AMAPCPI X X 

TBD

/ 

TBD 

Clinical 

Process/ 

Effective

ness 

Stroke and Stroke Rehabilitation: 

Tissue Plasminogen Activator (tPA) Administered Initiated (Paired 

Measure): Percentage of all patients 

aged 18 years and older with a 

diagnosis of ischemic stroke who 

present within two hours of time last 

known well and who are eligible for 

t-PA, for whom t-PA was initiated 

within three hours of time last known 

AMAPCPI X X 
CMS-1590-P 361 

Reporting 

Mechanism 

NQF/ PQRS 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-Selected GPRO (web interface)* Measures Groups 

Other Quality Reporting Programs 

well

0729

/ 

TBD 

Clinical 

Process/ 

Effective

ness 

Diabetes Composite: Optimal 

Diabetes Care: Patients ages 18 

through 75 with a diagnosis of 

diabetes, who meet all the numerator 

targets of this composite measure: 

A1c < 8.0%, LDL < 100 mg/dL, 

blood pressure < 140/90 mmHg, 

tobacco non-user and for patients 

with a diagnosis of ischemic vascular 

disease daily aspirin use unless 

contraindicated

MNC

M 

 X ACO 

0658

/ 

TBD 

Care 

Coordina

tion 

Endoscopy and Polyp Surveillance: 

Appropriate Follow-Up Interval 

for Normal Colonoscopy in 

Average Risk Patients: Percentage 

of patients aged 50 years and older 

receiving a screening colonoscopy 

without biopsy or polypectomy who 

had a recommended follow-up 

interval of at least 10 years for repeat 

colonoscopy documented in their 

colonoscopy report

AMAPCPI X X 

0493

/ 

TBD 

Care 

Coordina

tion 

Participation by a Physician or 

Other Clinician in a Systematic 

Clinical Database Registry that 

Includes Consensus Endorsed 

Quality: Participation in a 

systematic qualified clinical database 

registry involves: 

a. Physician or other clinician 

submits standardized data elements 

to registry 

b. Data elements are applicable to 

consensus endorsed quality measures

c. Registry measures shall include at 

CMS/ 

QIP 

X X 
CMS-1590-P 362 

Reporting 

Mechanism 

NQF/ PQRS 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-Selected GPRO (web interface)* Measures Groups 

Other Quality Reporting Programs 

least two (2) representative NQF 

consensus endorsed measures for 

registry's clinical topic(s) and report 

on all patients eligible for the 

selected measures. 

d. Registry provides calculated 

measures results, benchmarking, and 

quality improvement information to 

individual physicians and clinicians. 

e. Registry must receive data from 

more than 5 separate practices and 

may not be located (warehoused) at 

an individual group’s practice. 

Participation in a national or statewide registry is encouraged for this 

measure. 

f. Registry may provide feedback 

directly to the provider’s local 

registry if one exists

0670

/ 

TBD 

Efficient 

Use of 

Healthca

re 

Resource

s 

Cardiac Stress Imaging Not 

Meeting Appropriate Use Criteria: 

Preoperative Evaluative in LowRisk Surgery Patients: Percentage 

of stress single-photon emission 

computed tomography (SPECT) 

myocardial perfusion imaging (MPI), 

stress echo, cardiac computed 

tomography angiography (CCTA), or 

cardiovascular magnetic resonance 

(CMR) performed in low risk surgery 

patients for preoperative evaluation 

 ACC X 

0671

/ 

TBD 

Efficient 

Use of 

Healthca

re 

Cardiac Stress Imaging Not 

Meeting Appropriate Use Criteria: 

Routine Testing After 

Percutaneous Coronary 

ACC X 
CMS-1590-P 363 

Reporting 

Mechanism 

NQF/ PQRS 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-Selected GPRO (web interface)* Measures Groups 

Other Quality Reporting Programs 

Resource

s 

Intervention (PCI): Percentage of 

all stress single-photon emission 

computed tomography (SPECT) 

myocardial perfusion imaging (MPI) 

and stress echo performed routinely 

after percutaneous cardiology 

intervention (PCI), with reference to 

timing of test after PCI and symptom 

status

0672

/ 

TBD 

Efficient 

Use of 

Healthca

re 

Resource

s 

Cardiac Stress Imaging Not 

Meeting Appropriate Use Criteria: 

Testing in Asyptomatic, Low-Risk 

Patients: Percentage of all stress 

single-photon emission computed 

tomography (SPECT) myocardial 

perfusion imaging (MPI), stress 

echo, cardiac computed tomography 

angiography (CCTA), and 

cardiovascular magnetic resonance 

(CMR) performed in asymptomatic, 

low coronary heart disease (CHD) 

risk patients for intial detection and 

risk assessment

ACC X 

TBD

/ 

TBD 

Clinical 

Process/ 

Effective

ness 

Adult Major Depressive Disorder: 

Coordination of Care of Patients 

with Co-Morbid Conditions - 

Timely Follow-Up: Percentage of 

medical records of patients aged 18 

years and older with a diagnosis of 

MDD and a diagnosed co-morbid 

condition being treated by another 

physician with communication to the 

other physician treating the comorbid condition 

AMAPCPI  X 

TBD

/ 

Care 

Coordina

Coordination of Care of Patients 

with Co-Morbid Conditions - 

AMAPCPI  X 
CMS-1590-P 364 

Reporting 

Mechanism 

NQF/ PQRS 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-Selected GPRO (web interface)* Measures Groups 

Other Quality Reporting Programs 

TBD tion Timely Follow-Up (Paired 

Measure): Percentage of medical 

records of patients aged 18 years and 

older with a diagnosis of major 

depressive disorder (MDD) and a 

diagnosed co-morbid condition with 

communication to another physician 

treating the co-morbid condition who 

have a response from the other 

physician within 45 days of original 

communication OR who have a 

follow-up attempt within 60 days of 

original communication by the 

physician treating MDD to elicit a 

response from the other physician 

1525

/ 

TBD 

Patient 

Safety 

Atrial Fibrillation and Atrial 

Flutter: Chronic Anticoagulation 

Therapy: Percentage of patients 

aged 18 and older with nonvalvular 

AF or atrial flutter at high risk for 

thromboembolism, according to 

CHADS2 risk stratification, who 

were presecribed warfarin or another 

oral anticoagulant drug that is FDA 

approved for the prevention of 

thromboembolism during the 12-

month reporting period

AMA X X HITEC

H 

TBD

/ 

TBD 

Clinical 

Process/ 

Effective

ness 

Pediatric End-Stage Renal Disease 

Measure (AMA/ASPN): 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 

AMA/

ASPN 

X X 
CMS-1590-P 365 

Reporting 

Mechanism 

NQF/ PQRS 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-Selected GPRO (web interface)* Measures Groups 

Other Quality Reporting Programs 

(ESRD) undergoing maintenance 

hemodialysis in an outpatient dialysis 

facility have an assessment of the 

adequacy of volume management 

from a nephrologist 

1667

/ 

TBD 

Clinical 

Process/ 

Effective

ness 

Pediatric Kidney Disease: ESRD 

Patients Receiving Dialysis: 

Hemoglobin Level <10g/dL: 

Percentage of calendar months 

within a 12-month period during 

which patients aged 17 years and 

younger with a diagnosis of ESRD 

receiving hemodialysis or peritoneal 

dialysis have a Hemoglobin level 

<10 g/dL

AMA X X 

*Measures that can be reported using the GPRO web interface. 

†

These measures can only be reported by participants using the GPRO. They are not available for reporting for 

individual Eligible Professionals using this reporting method. 

¥ Titles and descriptions in this table may differ from existing measures in other programs. Please reference the 

National Quality Forum (NQF) and PQRS numbers for clarification. 

Although we are proposing to add measures that were not available for reporting under 

the 2012 PQRS, we note that we are not proposing to retain certain measures from the 2012 

PQRS. For reference, in Table 31 we list 14 measures from the 2012 PQRS that we are not 

proposing for the 2013 PQRS. 
CMS-1590-P 366 

TABLE 31: Measures Included in the 2012 PQRSs Measure Set that are Not Proposed to 

be Included in the Physician Quality Reporting Program Measure Set for 2013 and Beyond 

Reporting 

Mechanism 

NQF/ PQRS 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward PQRS Claims PQRS Qualified Registry CMS-Selected EHR CMS-Selected GPRO (web interface)* Measures Groups Other Quality Reporting Programs 

0246/ 

10 

Clinical 

Process/ 

Effective

ness 

Stroke and Stroke Rehabilitation: 

Computed Tomography (CT) or 

Magnetic Resonance Imaging 

(MRI) Reports: Percentage of final 

reports for CT or MRI studies of the 

brain performed either: 

• In the hospital within 24 hours of 

arrival, OR 

• In an outpatient imaging center 

to confirm initial diagnosis of stroke, 

transient ischemic attack (TIA) or 

intracranial hemorrhage 

For patients aged 18 years and older 

with either a diagnosis of ischemic 

stroke, TIA or intracranial 

hemorrhage OR at least one 

documented symptom consistent 

with ischemic stroke, TIA or 

intracranial hemorrhage that 

includes documentation of the 

presence or absence of each of the 

following: hemorrhage, mass lesion 

and acute infarction 

AMAPCPI/

NCQA

X X

 

 HITECH

0094/ 

57 

Clinical 

Process/ 

Effective

ness 

Emergency Medicine: 

Community-Acquired Pneumonia 

(CAP): Assessment of Oxygen 

Saturation: Percentage of patients 

aged 18 years and older with a 

diagnosis of community-acquired 

bacterial pneumonia with oxygen 

saturation documented and reviewed 

AMAPCPI/

NCQA

X X

 

 X 

0095/

58 

Clinical 

Process/ 

Effective

Emergency Medicine: 

Community-Acquired Pneumonia 

(CAP): Assessment of Mental 

AMAPCPI/

NCQA

X X X 
CMS-1590-P 367 

Reporting 

Mechanism 

NQF/ PQRS 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward PQRS Claims PQRS Qualified Registry CMS-Selected EHR CMS-Selected GPRO (web interface)* Measures Groups Other Quality Reporting Programs 

ness Status: Percentage of patients aged 

18 years and older with a diagnosis 

of community-acquired bacterial 

pneumonia with mental status 

assessed 

AQA 

adopt

ed/ 

92 

Clinical 

Process/ 

Effective

ness 

Acute Otitis Externa (AOE): Pain 

Assessment: Percentage of patient 

visits for those patients aged 2 years 

and older with a diagnosis of AOE 

with assessment for auricular or 

periauricular pain 

AMAPCPI X X

 

 

0488/ 

124 

Care 

Coordina

tion 

Health Information Technology 

(HIT): Adoption/Use of Electronic 

Health Records (EHR): 

Documents whether provider has 

adopted and is using health 

information technology. To report 

this measure, the eligible 

professional must have adopted and 

be using a certified, Physician 

Quality Reporting System qualified 

or other acceptable EHR system 

CMS/

QIP 

X X

 

 

0466/ 

158 

Clinical 

Process/ 

Effective

ness 

Carotid Endarterectomy: Use of 

Patch During Conventional 

Carotid Endarterectomy: 

Percentage of patients aged 18 years 

and older undergoing conventional 

(non-eversion) carotid 

endarterectomy (CEA) who undergo 

patch closure of the arteriotomy 

 SVS X X 

AQA 

adopt

ed/ 

186 

Clinical 

Process/ 

Effective

ness 

Chronic Wound Care: Use of 

Compression System in Patients 

with Venous Ulcers: Percentage of 

patients aged 18 years and older 

with a diagnosis of venous ulcer 

who were prescribed compression 

AMAPCPI/

NCQA

X X

 

 
CMS-1590-P 368 

Reporting 

Mechanism 

NQF/ PQRS 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward PQRS Claims PQRS Qualified Registry CMS-Selected EHR CMS-Selected GPRO (web interface)* Measures Groups Other Quality Reporting Programs 

therapy within the 12-month 

reporting period 

N/A/ 

189 

Care 

Coordina

tion 

Referral for Otologic Evaluation 

for Patients with History of Active 

Drainage from the Ear Within the 

Previous 90 Days: Percentage of 

patients aged birth and older who 

have disease of the ear and mastoid 

processes referred to a physician 

(preferably a physician with training 

in disorders of the ear) for an 

otologic evaluation subsequent to an 

audiologic evaluation after 

presenting with a history of active 

drainage from the ear within the 

previous 90 days 

AQC X X 

N/A/ 

190 

Care 

Coordina

tion 

Referral for Otologic Evaluation 

for Patients with a History of 

Sudden or Rapidly Progressive 

Hearing Loss: Percentage of 

patients aged birth and older referred 

to a physician (preferably a 

physician with training in disorders 

of the ear) for an otologic evaluation 

immediately following an audiologic 

evaluation that verifies and 

documents sudden or rapidly 

progressive hearing loss 

AQC X

 

X

 

 

0065/ 

196 

Clinical 

Process/ 

Effective

ness 

Coronary Artery Disease (CAD): 

Symptom and Activity 

Assessment: Percentage of patients 

aged 18 years and older with a 

diagnosis of coronary artery disease 

seen within a 12 month period for 

whom there are documented results 

of an evaluation of level of activity 

AMAPCPI/

ACCF

/AHA 

 X

 

 X 
CMS-1590-P 369 

Reporting 

Mechanism 

NQF/ PQRS 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward PQRS Claims PQRS Qualified Registry CMS-Selected EHR CMS-Selected GPRO (web interface)* Measures Groups Other Quality Reporting Programs 

AND an evaluation of presence or 

absence of anginal symptoms in the 

medical record 

0082/ 

199 

Clinical 

Process/ 

Effective

ness 

Heart Failure: Patient Education: 

Percentage of patients aged 18 years 

and older with a diagnosis of heart 

failure who were provided with 

patient education on disease 

management and health behavior 

changes during one or more visit(s) 

within 12 months 

CMS/

QIP 

 X 

0447/ 

212 

Care 

Coordina

tion 

Functional Communication 

Measure - Motor Speech: 

Percentage of patients aged 16 years 

and older with a diagnosis of late 

effects of cerebrovascular disease 

(CVD) that make progress on the 

Motor Speech Functional 

Communication Measure 

ASHA X 

0017/

235 

Clinical 

Process/ 

Effective

ness 

Hypertension (HTN): Plan of 

Care: Percentage of patient visits 

for patients aged 18 years and older 

with a diagnosis of HTN during 

which either systolic blood pressure 

≥ 140 mmHg OR diastolic blood 

pressure ≥ 90mm Hg, with 

documented plan of care for 

hypertension 

CMS/

QIP 

X

 

X

 

 

0502/ 

253 

Clinical 

Process/ 

Effective

ness 

Pregnancy Test for Female 

Abdominal Pain Patients: 

Percentage of female patients aged 

14 to 50 who present to the 

emergency department (ED) with a 

chief complaint of abdominal pain 

for whom a pregnancy test ordered 

ACEP X X

 

 

*Measures that can be reported using the GPRO web interface. 
CMS-1590-P 370 

¥ Titles and descriptions in this table are aligned with the proposed 2013 PQRS Electronic Health Records (EHR) 

measure titles, and may differ from existing measures in other programs. Please reference the National Quality 

Forum (NQF) and PQRS numbers for clarification. 

A summary of the measures we are proposing for 2013 and beyond are specified in Table 

32. Table 32 specifies our proposals to propose all measures that were available for reporting in 

PQRS in 2012, with the exception of the measures listed in Table 31, as well as propose new 

measures specified in Table 30 not available for reporting under PQRS in prior years. 

TABLE 32: Proposed PQRS Individual Quality Measures Available for Reporting via 

Claims, Registry, EHR, or GRPO Web-Interface for 2013 and Beyond 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

0059/ 

1 

 Clinical 

Process/ 

Effectivenes

s 

Diabetes Mellitus: 

Hemoglobin A1c Poor 

Control in Diabetes 

Mellitus: Percentage of 

patients aged 18 through 

75 years with diabetes 

mellitus who had most 

recent hemoglobin A1c 

greater than 9.0% 

NCQA X X X X X HITE

CH 

ACO 

0064/ 

2 

 Clinical 

Process/ 

Effectivenes

s 

Diabetes Mellitus: Low 

Density Lipoprotein 

(LDL-C) Control in 

Diabetes Mellitus: 

Percentage of patients 

aged 18 through 75 years 

with diabetes mellitus 

who had most recent 

LDL-C level in control 

(less than 100 mg/dL) 

NCQA X X X X HITE

CH 

Millio

n 

Hearts 

0061/ 

3 

 Clinical 

Process/ 

Effectivenes

Diabetes Mellitus: High 

Blood Pressure Control 

in Diabetes Mellitus: 

NCQA X X X X HITE

CH 
CMS-1590-P 371 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

s Percentage of patients 

aged 18 through 75 years 

with diabetes mellitus 

who had most recent 

blood pressure in control 

(less than 140/90 mmHg) 

0081/ 

5 

 Clinical 

Process/ 

Effectivenes

s 

Heart Failure: 

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 and LVSD 

(LVEF < 40%) who were 

prescribed ACE inhibitor 

or ARB therapy 

AMAPCPI/ 

ACCF/A

HA 

 X X X HITE

CH 

0067/ 

6 

 Clinical 

Process/ 

Effectivenes

s 

Coronary Artery Disease 

(CAD): Antiplatelet 

Therapy: Percentage of 

patients aged 18 years and 

older with a diagnosis of 

coronary artery disease 

seen within a 12 month 

period who were 

prescribed aspirin or 

clopidogrel 

AMAPCPI/ 

ACCF/A

HA 

X X X X 

0070/ 

7 

 Clinical 

Process/ 

Effectivenes

s 

Coronary Artery Disease 

(CAD): Beta-Blocker 

Therapy for CAD 

Patients with Prior 

Myocardial Infarction 

(MI): Percentage of 

AMAPCPI/ 

ACCF/A

HA 

 X X HITE

CH 
CMS-1590-P 372 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

patients aged 18 years and 

older with a diagnosis of 

CAD and prior MI who 

were prescribed betablocker therapy 

0083/ 

8 

 Clinical 

Process/ 

Effectivenes

s 

Heart Failure: BetaBlocker Therapy for 

Left Ventricular Systolic 

Dysfunction (LVSD): 

Percentage of patients 

aged 18 years and older 

with a diagnosis of heart 

failure who also have 

LVSD (LVEF < 40%) and 

who were prescribed betablocker therapy 

AMAPCPI/ 

ACCF/A

HA 

 X X X X HITE

CH 

ACO 

0105/ 

9 

 Clinical 

Process/ 

Effectivenes

s 

Anti-depressant 

medication 

management: (a) 

Effective Acute Phase 

Treatment, (b) Effective 

Continuation Phase 

Treatment: The 

percentage of patients 18 

years of age and older 

who were diagnosed with 

a new episode of major 

depression, treated with 

antidepressant medication, 

and who remained on an 

antidepressant medication 

treatment 

NCQA X X X HITE

CH 

0086/ 

12 

 Clinical 

Process/ 

Effectivenes

s 

Primary Open Angle 

Glaucoma (POAG): 

Optic Nerve Evaluation: 

Percentage of patients 

AMAPCPI/ 

NCQA 

X X X HITE

CH 
CMS-1590-P 373 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

aged 18 years and older 

with a diagnosis of POAG 

who have an optic nerve 

head evaluation during 

one or more office visits 

within 12 months 

0087/ 

14 

 Clinical 

Process/ 

Effectivenes

s 

Age-Related Macular 

Degeneration (AMD): 

Dilated Macular 

Examination: Percentage 

of patients aged 50 years 

and older with a diagnosis 

of AMD who had a 

dilated macular 

examination performed 

which included 

documentation of the 

presence or absence of 

macular thickening or 

hemorrhage AND the 

level of macular 

degeneration severity 

during one or more office 

visits within 12 months 

AMAPCPI/ 

NCQA 

X X 

0088/ 

18 

 Clinical 

Process/ 

Effectivenes

s 

Diabetic Retinopathy: 

Documentation of 

Presence or Absence of 

Macular Edema and 

Level of Severity of 

Retinopathy: Percentage 

of patients aged 18 years 

and older with a diagnosis 

of diabetic retinopathy 

who had a dilated macular 

or fundus exam performed 

which included 

AMAPCPI/ 

NCQA 

X X X HITE

CH 
CMS-1590-P 374 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

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 

0089/ 

19 

 Clinical 

Process/ 

Effectivenes

s 

Diabetic Retinopathy: 

Communication with the 

Physician Managing Ongoing Diabetes Care: 

Percentage of patients 

aged 18 years and older 

with a diagnosis of 

diabetic retinopathy who 

had a dilated macular or 

fundus exam performed 

with documented 

communication to the 

physician who manages 

the on-going care of the 

patient with diabetes 

mellitus regarding the 

findings of the macular or 

fundus exam at least once 

within 12 months 

AMAPCPI/ 

NCQA 

X X X HITE

CH 

0270/ 

20 

 Patient 

Safety 

Perioperative Care: 

Timing of Antibiotic 

Prophylaxis – 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 

AMAPCPI/ 

NCQA 

X X X 
CMS-1590-P 375 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

parenteral antibiotic to be 

given within one hour (if 

fluoroquinolone or 

vancomycin, two hours), 

prior to the surgical 

incision (or start of 

procedure when no 

incision is required) 

0268/ 

21 

 Patient 

Safety 

Perioperative Care: 

Selection of Prophylactic 

Antibiotic – First OR 

Second Generation 

Cephalosporin: 

Percentage of surgical 

patients aged 18 years and 

older undergoing 

procedures with the 

indications for a first OR 

second generation 

cephalosporin 

prophylactic antibiotic, 

who had an order for 

cefazolin OR cefuroxime 

for antimicrobial 

prophylaxis 

AMAPCPI/ 

NCQA 

X X X 

0271/ 

22 

 Patient 

Safety 

Perioperative Care: 

Discontinuation of 

Prophylactic Antibiotics 

(Non-Cardiac 

Procedures): Percentage 

of non-cardiac surgical 

patients aged 18 years and 

older undergoing 

procedures with the 

indications for 

prophylactic parenteral 

AMAPCPI/ 

NCQA 

X X X 
CMS-1590-P 376 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

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 

0239/ 

23 

 Patient 

Safety 

Perioperative Care: 

Venous 

Thromboembolism 

(VTE) Prophylaxis 

(When Indicated in ALL 

Patients): Percentage of 

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 

AMAPCPI/ 

NCQA 

X X X 

0045/ 

24 

 Care 

Coordinatio

n 

Osteoporosis: 

Communication with the 

Physician Managing Ongoing Care PostFracture of Hip, Spine 

or Distal Radius for Men 

AMAPCPI/ 

NCQA 

X X 
CMS-1590-P 377 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

and Women Aged 50 

Years and Older: 

Percentage of patients 

aged 50 years and older 

treated for a hip, spine or 

distal radial fracture with 

documentation of 

communication with the 

physician managing the 

patient’s on-going care 

that a fracture occurred 

and that the patient was or 

should be tested or treated 

for osteoporosis 

0092/ 

28 

 Clinical 

Process/ 

Effectivenes

s 

Aspirin at Arrival for 

Acute Myocardial 

Infarction (AMI): 

Percentage of patients, 

regardless of age, with an 

emergency department 

discharge diagnosis of 

AMI who had 

documentation of 

receiving aspirin within 

24 hours before 

emergency department 

arrival or during 

emergency department 

stay 

AMAPCPI/ 

NCQA 

X X 

0269/ 

30 

 Patient 

Safety 

Perioperative Care: 

Timely Administration 

of Prophylactic 

Parenteral Antibiotics: 

Percentage of surgical 

patients aged 18 years and 

older who receive an 

AMAPCPI/ 

NCQA 

X X 
CMS-1590-P 378 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

anesthetic when 

undergoing procedures 

with the indications for 

prophylactic parenteral 

antibiotics for whom 

administration of the 

prophylactic parenteral 

antibiotic ordered has 

been initiated within one 

hour (if fluoroquinolone 

or vancomycin, two 

hours) prior to the surgical 

incision (or start of 

procedure when no 

incision is required) 

0240/ 

31 

 Clinical 

Process/ 

Effectivenes

s 

Stroke and Stroke 

Rehabilitation: Deep 

Vein Thrombosis (DVT) 

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 

DVT prophylaxis by end 

of hospital day two 

AMAPCPI/ 

NCQA 

X X 

0325/ 

32 

 Clinical 

Process/ 

Effectivenes

s 

Stroke and Stroke 

Rehabilitation: 

Discharged on 

Antithrombotic 

Therapy: Percentage of 

patients aged 18 years and 

older with a diagnosis of 

ischemic stroke or 

AMAPCPI/ 

NCQA 

X X 
CMS-1590-P 379 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

transient ischemic attack 

(TIA) who were 

prescribed antithrombotic 

therapy at discharge 

0241/ 

33 

 Clinical 

Process/ 

Effectivenes

s 

Stroke and Stroke 

Rehabilitation: 

Anticoagulant Therapy 

Prescribed for Atrial 

Fibrillation (AF) at 

Discharge: Percentage of 

patients aged 18 years and 

older with a diagnosis of 

ischemic stroke or 

transient ischemic attack 

(TIA) with documented 

permanent, persistent, or 

paroxysmal atrial 

fibrillation who were 

prescribed an 

anticoagulant at discharge 

AMAPCPI/ 

NCQA 

 X 

0243/ 

35 

 Clinical 

Process/ 

Effectivenes

s 

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 

AMAPCPI/ 

NCQA 

X X 
CMS-1590-P 380 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

institution in which the 

patient is receiving care 

0244/ 

36 

 Clinical 

Process/ 

Effectivenes

s 

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 

AMAPCPI/ 

NCQA 

X X 

0046/ 

39 

 Clinical 

Process/ 

Effectivenes

s 

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 Xray absorptiometry (DXA) 

measurement ordered or 

performed at least once 

since age 60 or 

pharmacologic therapy 

prescribed within 12 

months 

AMAPCPI/ 

NCQA 

X X X X 

0048/ 

40 

 Clinical 

Process/ 

Effectivenes

Osteoporosis: 

Management Following 

Fracture of Hip, Spine 

AMAPCPI/ 

NCQA 

X X 
CMS-1590-P 381 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

s 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 

0049/ 

41 

 Clinical 

Process/ 

Effectivenes

s 

Osteoporosis: 

Pharmacologic Therapy 

for Men and Women 

Aged 50 Years and 

Older: Percentage of 

patients aged 50 years 

and older with a 

diagnosis of osteoporosis 

who were prescribed 

pharmacologic therapy 

within 12 months 

AMAPCPI/ 

NCQA 

X X 

0134/ 

43 

 Clinical 

Process/ 

Effectivenes

s 

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 using an 

IMA graft 

STS X X X 

0236/ 

44 

 Clinical 

Process/ 

Coronary Artery Bypass 

Graft (CABG): 

CMS/ 

QIP 

X X X 
CMS-1590-P 382 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

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electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

Effectivenes

s 

Preoperative BetaBlocker in Patients with 

Isolated CABG Surgery: 

Percentage of patients 

aged 18 years and older 

undergoing isolated 

CABG surgery who 

received a beta-blocker 

within 24 hours prior to 

surgical incision 

0637/ 

45 

 Patient 

Safety 

Perioperative Care: 

Discontinuation of 

Prophylactic Antibiotics 

(Cardiac Procedures): 

Percentage of cardiac 

surgical patients aged 18 

years and older 

undergoing procedures 

with the indications for 

prophylactic antibiotics 

AND who received a 

prophylactic antibiotic, 

who have an order for 

discontinuation of 

prophylactic antibiotics 

within 48 hours of 

surgical end time 

AMAPCPI/ 

NCQA 

X X 

0097/ 

46 

 Patient 

Safety 

Medication 

Reconciliation: 

Reconciliation After 

Discharge from an 

Inpatient Facility: 

Percentage of patients 

aged 65 years and older 

discharged from any inpat

ient facility (e.g., hospital, 

AMAPCPI/ 

NCQA 

X X X ACO 
CMS-1590-P 383 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

skilled nursing facility, or 

rehabilitation facility) and 

seen within 60 days follo

wing discharge in the 

office by the physician 

providing on-going care 

who had a reconciliation 

of the discharge 

medications with the 

current medication list in 

the medical record 

documented 

0326/

47 

 Care 

Coordinatio

n 

Advanced Care Plan:

Percentage of patients 

aged 65 years and older 

who have an advanced 

care plan or surrogate 

decision maker 

documented in the 

medical record or 

documentation in the 

medical record that an 

advanced care plan was 

discussed but the patient 

did not wish or was not 

able to name a surrogate 

decision maker or provide 

an advanced care plan

AMAPCPI/NC

QA 

X X X 

0098/ 

48 

 Clinical 

Process/ 

Effectivenes

s 

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 

AMAPCPI/ 

NCQA 

X X X X 
CMS-1590-P 384 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

assessed for the presence 

or absence of urinary 

incontinence within 12 

months 

0099/ 

49 

 Clinical 

Process/ 

Effectivenes

s 

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 

AMAPCPI/ 

NCQA 

X X 

0100/ 

50 

 Patient and 

Family 

Engagement 

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 

AMAPCPI/ 

NCQA 

X X 

0091/ 

51 

 Clinical 

Process/ 

Effectivenes

s 

Chronic Obstructive 

Pulmonary Disease 

(COPD): Spirometry 

Evaluation: Percentage of 

patients aged 18 years and 

older with a diagnosis of 

COPD who had 

AMAPCPI 

X X X 
CMS-1590-P 385 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

spirometry evaluation 

results documented 

0102/ 

52 

 Clinical 

Process/ 

Effectivenes

s 

Chronic Obstructive 

Pulmonary Disease 

(COPD): Bronchodilator 

Therapy: 

Percentage of patients 

aged 18 years and older 

with a diagnosis of COPD 

and who have an 

FEV1/FVC less than 70% 

and have symptoms who 

were prescribed an 

inhaled bronchodilator 

AMAPCPI 

X X X 

0047/ 

53 

 Clinical 

Process/ 

Effectivenes

s 

Asthma: Pharmacologic 

Therapy for Persistent 

Asthma: Percentage of 

patients aged 5 through 50 

years with a diagnosis of 

mild, moderate, or severe 

persistent asthma who 

were prescribed either the 

preferred long-term 

control medication 

(inhaled corticosteroid) or 

an acceptable alternative 

treatment 

AMAPCPI/ 

NCQA 

X X X X 

0090/ 

54 

 Clinical 

Process/ 

Effectivenes

s 

Emergency Medicine: 

12-Lead 

Electrocardiogram 

(ECG) Performed for 

Non- Traumatic Chest 

Pain: Percentage of 

patients aged 40 years and 

older with an emergency 

department discharge 

AMAPCPI/ 

NCQA 

X X 
CMS-1590-P 386 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

diagnosis of non-traumatic 

chest pain who had a 12-

lead ECG performed 

0093/ 

55 

 Clinical 

Process/ 

Effectivenes

s 

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 ECG 

performed 

AMAPCPI/ 

NCQA 

X X 

0232/ 

56 

 Clinical 

Process/ 

Effectivenes

s 

Emergency Medicine: 

Community-Acquired 

Pneumonia (CAP): Vital 

Signs: Percentage of 

patients aged 18 years and 

older with a diagnosis of 

community-acquired 

bacterial pneumonia with 

vital signs documented 

and reviewed 

AMAPCPI/ 

NCQA 

X X 

0096/ 

59 

 Clinical 

Process/ 

Effectivenes

s 

Emergency Medicine: 

Community-Acquired 

Pneumonia (CAP): 

Empiric Antibiotic: 

Percentage of patients 

aged 18 years and older 

with a diagnosis of 

community-acquired 

bacterial pneumonia with 

an appropriate empiric 

antibiotic prescribed 

AMAPCPI/ 

NCQA 

X X 

0001/ Clinical Asthma: Assessment of AMA- X X X X 
CMS-1590-P 387 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

64 Process/ 

Effectivenes

s 

Asthma Control: 

Percentage of patients 

aged 5 through 50 years 

with a diagnosis of asthma 

who were evaluated 

during at least one office 

visit within 12 months for 

the frequency (numeric) 

of daytime and nocturnal 

asthma symptoms 

PCPI/ 

NCQA 

0069/ 

65 

 Efficient 

Use of 

Healthcare 

Resources 

Treatment for Children 

with Upper Respiratory 

Infection (URI): 

Avoidance of 

Inappropriate Use: 

Percentage of children 

aged 3 months through 18 

years with a diagnosis of 

URI who were 

not prescribed or dispense

d an antibiotic 

prescription on or within 3 

days of the initial date of 

service 

NCQA X X HITE

CH 

0002/ 

66 

 Efficient 

Use of 

Healthcare 

Resources 

Appropriate Testing for 

Children with 

Pharyngitis: Percentage 

of children aged 2 through 

18 years with a diagnosis 

of pharyngitis, who were 

prescribed an antibiotic 

and who received a group 

A streptococcus (strep) 

test for the episode 

NCQA X X X HITE

CH 

0377/ 

67 

 Clinical 

Process/ 

Hematology: 

Myelodysplastic 

AMAPCPI/ 

X X 
CMS-1590-P 388 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

Effectivenes

s 

Syndrome (MDS) and 

Acute Leukemias: 

Baseline 

Cytogenetic Testing 

Performed on Bone 

Marrow: Percentage of 

patients aged 18 years and 

older with a diagnosis of 

MDS or an acute leukemia 

who had baseline 

cytogenetic testing 

performed on bone 

marrow 

ASH 

0378/ 

68 

 Clinical 

Process/ 

Effectivenes

s 

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 MDS 

who are receiving 

erythropoietin therapy 

with documentation of 

iron stores prior to 

initiating erythropoietin 

therapy 

AMAPCPI/ 

ASH 

X X 

0380/ 

69 

 Clinical 

Process/ 

Effectivenes

s 

Hematology: Multiple 

Myeloma: Treatment 

with Bisphosphonates: 

Percentage of patients 

aged 18 years and older 

with a diagnosis of 

multiple myeloma, not in 

AMAPCPI/ 

ASH 

X X 
CMS-1590-P 389 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

remission, who were 

prescribed or received 

intravenous 

bisphosphonate therapy 

within the 12-month 

reporting period 

0379/ 

70 

 Clinical 

Process/ 

Effectivenes

s 

Hematology: Chronic 

Lymphocytic Leukemia 

(CLL): Baseline Flow 

Cytometry: Percentage of 

patients aged 18 years and 

older with a diagnosis of 

CLL who had baseline 

flow cytometry studies 

performed 

AMAPCPI/ 

ASH 

X X 

0387/ 

71 

 Clinical 

Process/ 

Effectivenes

s 

Breast Cancer: 

Hormonal Therapy for 

Stage IC-IIIC Estrogen 

Receptor/Progesterone 

Receptor (ER/PR) 

Positive Breast Cancer: 

Percentage of female 

patients aged 18 years and 

older with Stage IC 

through IIIC, ER or PR 

positive breast cancer who 

were prescribed tamoxifen 

or aromatase inhibitor 

(AI) during the 12-month 

reporting period 

AMAPCPI/ 

ASCO/N

CCN 

X X X X HITE

CH 

0385/ 

72 

 Clinical 

Process/ 

Effectivenes

s 

Colon Cancer: 

Chemotherapy for Stage 

III Colon Cancer 

Patients: Percentage of 

patients aged 18 years and 

older with Stage IIIA 

AMAPCPI/ 

ASCO/N

CCN 

X X X X HITE

CH 

 
CMS-1590-P 390 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

through IIIC colon cancer 

who are referred for 

adjuvant chemotherapy, 

prescribed adjuvant 

chemotherapy, or have 

previously received 

adjuvant chemotherapy 

within the 12-month 

reporting period 

0464/ 

76 

 Patient 

Safety 

Prevention of CatheterRelated Bloodstream 

Infections (CRBSI): 

Central Venous Catheter 

(CVC) Insertion 

Protocol: Percentage of 

patients, regardless of age, 

who undergo CVC 

insertion for whom CVC 

was inserted with all 

elements of maximal 

sterile barrier technique 

[cap AND mask AND 

sterile gown AND sterile 

gloves AND a large sterile 

sheet AND hand hygiene 

AND 2% chlorhexidine 

for cutaneous antisepsis 

(or acceptable alternative 

antiseptics per current 

guideline)] followed 

AMAPCPI X X 

0323/ 

81 

 Care 

Coordinatio

n 

Adult Kidney Disease: 

Hemodialysis Adequacy: 

Solute: Percentage of 

calendar months within a 

12-month period during 

which patients aged 18 

AMAPCPI  X 
CMS-1590-P 391 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

years and older with a 

diagnosis of ESRD 

receiving hemodialysis 

three times a week who 

have a spKt/V ≥ 1.2 

0321/ 

82 

 Care 

Coordinatio

n 

Adult Kidney Disease: 

Peritoneal Dialysis 

Adequacy: Solute: 

Percentage of patients 

aged 18 years and older 

with a diagnosis of ESRD 

receiving peritoneal 

dialysis who have a total 

Kt/V ≥ 1.7 per week 

measured once every 4 

months 

AMAPCPI 

 X 

0393/ 

83 

 Clinical 

Process/ 

Effectivenes

s 

Hepatitis C: Testing for 

Chronic Hepatitis C – 

Confirmation of 

Hepatitis C Viremia: 

Percentage of patients 

aged 18 years and older 

with a diagnosis of 

hepatitis C seen for an 

initial evaluation who had 

HCV RNA testing ordered 

or previously performed 

AMAPCPI  X 

0395/ 

84 

 Clinical 

Process/ 

Effectivenes

s 

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 

are receiving antiviral 

treatment for whom 

AMAPCPI X X X 
CMS-1590-P 392 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

quantitative HCV RNA 

testing was performed 

within 6 months prior to 

initiation of antiviral 

treatment 

0396/ 

85 

 Clinical 

Process/ 

Effectivenes

s 

Hepatitis C: HCV 

Genotype Testing Prior 

to Treatment: Percentage 

of patients aged 18 years 

and older with a diagnosis 

of chronic hepatitis C who 

are receiving antiviral 

treatment for whom HCV 

genotype testing was 

performed prior to 

initiation of antiviral 

treatment 

AMAPCPI 

X X X 

0397/ 

86 

 Clinical 

Process/ 

Effectivenes

s 

Hepatitis C: Antiviral 

Treatment Prescribed: 

Percentage of patients 

aged 18 years and older 

with a diagnosis of 

chronic hepatitis C who 

were prescribed at a 

minimum peginterferon 

and ribavirin therapy 

within the 12-month 

reporting period 

AMAPCPI 

X X X 

0398/ 

87 

 Clinical 

Process/ 

Effectivenes

s 

Hepatitis C: HCV 

Ribonucleic Acid (RNA) 

Testing at Week 12 of 

Treatment: Percentage of 

patients aged 18 years and 

older with a diagnosis of 

chronic hepatitis C who 

are receiving antiviral 

AMAPCPI X X X 
CMS-1590-P 393 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

treatment for whom 

quantitative HCV RNA 

testing was performed at 

no greater than 12 weeks 

from the initiation of 

antiviral treatment 

0401/ 

89 

 Clinical 

Process/ 

Effectivenes

s 

Hepatitis C: Counseling 

Regarding Risk of 

Alcohol Consumption: 

Percentage of patients 

aged 18 years and older 

with a diagnosis of 

hepatitis C who were 

counseled about the risks 

of alcohol use at least 

once within 12-months 

AMAPCPI X X X 

0394/ 

90 

 Clinical 

Process/ 

Effectivenes

s 

Hepatitis C: Counseling 

Regarding Use of 

Contraception Prior to 

Antiviral Therapy: 

Percentage of female 

patients aged 18 through 

44 years and all men aged 

18 years and older with a 

diagnosis of chronic 

hepatitis C who are 

receiving antiviral 

treatment who were 

counseled regarding 

contraception prior to the 

initiation of treatment 

AMAPCPI X X X 

0653/ 

91 

 Clinical 

Process/ 

Effectivenes

s 

Acute Otitis Externa 

(AOE): Topical 

Therapy: Percentage of 

patients aged 2 years and 

older with a diagnosis of 

AMAPCPI X X 
CMS-1590-P 394 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

AOE who were prescribed 

topical preparations 

0654/ 

93 

 Care 

Coordinatio

n 

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 

AMAPCPI 

X X 

0391/ 

99 

 Clinical 

Process/ 

Effectivenes

s 

Breast Cancer Resection 

Pathology Reporting: pT 

Category (Primary 

Tumor) and pN 

Category (Regional 

Lymph Nodes) with 

Histologic Grade: 

Percentage of breast 

cancer resection pathology 

reports that include the pT 

category (primary tumor), 

the pN category (regional 

lymph nodes), and the 

histologic grade 

AMAPCPI/ 

CAP 

X X 

0392/ 

100 

 Clinical 

Process/ 

Effectivenes

s 

Colorectal Cancer 

Resection Pathology 

Reporting: pT Category 

(Primary Tumor) and 

pN Category (Regional 

Lymph Nodes) with 

Histologic Grade: 

Percentage of colon and 

rectum cancer resection 

AMAPCPI/ 

CAP 

X X 
CMS-1590-P 395 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

pathology reports that 

include the pT category 

(primary tumor), the pN 

category (regional lymph 

nodes) and the histologic 

grade 

0389/ 

102 

 Efficient 

Use of 

Healthcare 

Resources 

Prostate Cancer: 

Avoidance of Overuse of 

Bone Scan for Staging 

Low-Risk Prostate 

Cancer Patients: 

Percentage of patients, 

regardless of age, with a 

diagnosis of prostate 

cancer at low risk of 

recurrence receiving 

interstitial prostate 

brachytherapy, OR 

external beam 

radiotherapy to the 

prostate, OR radical 

prostatectomy, OR 

cryotherapy who did not

have a bone scan 

performed at any time 

since diagnosis of prostate 

cancer 

AMAPCPI X X X HITE

CH 

0390/ 

104 

 Clinical 

Process/ 

Effectivenes

s 

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 

AMAPCPI 

X X 
CMS-1590-P 396 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

receiving external beam 

radiotherapy to the 

prostate who were 

prescribed adjuvant 

hormonal therapy (GnRH 

agonist or antagonist) 

0388/ 

105 

 Patient 

Safety 

Prostate Cancer: Three 

Dimensional (3D) 

Radiotherapy: 

Percentage of patients, 

regardless of age, with a 

diagnosis of clinically 

localized prostate cancer 

receiving external beam 

radiotherapy as a primary 

therapy to the prostate 

with or without nodal 

irradiation (no metastases; 

no salvage therapy) who 

receive three-dimensional 

conformal radiotherapy 

(3D-CRT) or intensity 

modulated radiation 

therapy (IMRT) 

AMAPCPI X X 

0103/ 

106 

 Clinical 

Process/ 

Effectivenes

s 

Major Depressive 

Disorder (MDD): 

Diagnostic Evaluation: 

Percentage of patients 

aged 18 years and older 

with a new diagnosis or 

recurrent episode of MDD 

who met the DSM-IV 

criteria during the visit in 

which the new diagnosis 

or recurrent episode was 

identified during the 

AMAPCPI 

X X 
CMS-1590-P 397 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

measurement period 

0104/ 

107 

 Clinical 

Process/ 

Effectivenes

s 

Major Depressive 

Disorder (MDD): 

Suicide Risk 

Assessment: Percentage 

of patients aged 18 years 

and older with a new 

diagnosis or recurrent 

episode of MDD who had 

a suicide risk assessment 

completed at each visit 

during the measurement 

period 

AMAPCPI X X 

0054/ 

108 

 Clinical 

Process/ 

Effectivenes

s 

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 X X X 

0050/ 

109 

 Patient and 

Family 

Engagement 

Osteoarthritis (OA): 

Function and Pain 

Assessment: Percentage 

of patient visits for 

patients aged 21 years and 

older with a diagnosis of 

OA with assessment for 

function and pain 

AMAPCPI X X 

0041/ 

110 

 Population/

Public 

Health 

Preventive Care and 

Screening: Influenza 

Immunization: 

AMAPCPI X X X X X HITE

CH 

ACO 
CMS-1590-P 398 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

Percentage of patients 

aged 6 months and older 

who received an influenza 

immunization during the 

flu season (October 1 

through March 31) 

0043/ 

111 

 Clinical 

Process/ 

Effectivenes

s 

Preventive Care and 

Screening: Pneumonia 

Vaccination for Patients 

65 Years and Older: 

Percentage of patients 

aged 65 years and older 

who have ever received a 

pneumococcal vaccine 

NCQA X X X X X HITE

CH 

ACO 

0031/ 

112 

 Clinical 

Process/ 

Effectivenes

s 

Preventive Care and 

Screening: Screening 

Mammography: 

Percentage of women 

aged 40 through 69 years 

who had a mammogram to 

screen for breast cancer 

NCQA X X X X X HITE

CH 

ACO 

0034/ 

113 

 Clinical 

Process/ 

Effectivenes

s 

Preventive Care and 

Screening: Colorectal 

Cancer Screening: 

Percentage of patients 

aged 50 through 75 years 

who received the 

appropriate colorectal 

cancer screening 

NCQA X X X X X HITE

CH 

ACO 

0058/ 

116 

 Efficient 

Use of 

Healthcare 

Resources 

Antibiotic Treatment for 

Adults with Acute 

Bronchitis: Avoidance of 

Inappropriate Use: 

Percentage of adults aged 

18 through 64 years with a 

diagnosis of acute 

NCQA X X 
CMS-1590-P 399 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

bronchitis who were 

not prescribed or dispense

d an antibiotic 

prescription on or within 3 

days of the initial date of 

service 

0055/ 

117 

 Clinical 

Process/ 

Effectivenes

s 

Diabetes Mellitus: 

Dilated Eye Exam in 

Diabetic Patient: 

Percentage of patients 

aged 18 through 75 years 

with a diagnosis of 

diabetes mellitus who had 

a dilated eye exam 

NCQA X X X X HITE

CH 

0066/ 

118 

 Clinical 

Process/ 

Effectivenes

s 

Coronary Artery Disease 

(CAD): AngiotensinConverting Enzyme 

(ACE) Inhibitor or 

Angiotensin Receptor 

Blocker (ARB) Therapy 

for Patients with CAD 

and Diabetes and/or Left 

Ventricular Systolic 

Dysfunction (LVSD): 

Percentage of patients 

aged 18 years and older 

with a diagnosis of 

coronary artery disease 

seen within a 12 month 

period who also have 

diabetes OR a current or 

prior LVEF < 40% who 

were prescribed ACE 

inhibitor or ARB therapy 

AMAPCPI/ 

ACCF/A

HA 

 X X ACO 

0062/ 

119 

 Clinical 

Process/ 

Diabetes: Urine 

Screening: Percentage of 

NCQA X X X X HITE

CH 
CMS-1590-P 400 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

Effectivenes

s 

patients aged 18 through 

75 years with diabetes 

(type 1 or type 2) who had 

a nephropathy screening 

test or evidence of 

nephropathy 

AQA 

adopt

ed/ 

121 

 Clinical 

Process/ 

Effectivenes

s 

Adult Kidney: Disease 

Laboratory Testing 

(Lipid Profile): 

Percentage of patients 

aged 18 years and older 

with a diagnosis of 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 

AMAPCPI X X X 

AQA 

adopt

ed/ 

122 

 Clinical 

Process/ 

Effectivenes

s 

Adult Kidney Disease: 

Blood Pressure 

Management: Percentage 

of patient visits for those 

patients aged 18 years and 

older with a diagnosis of 

CKD (stage 3, 4, or 5, not 

receiving Renal 

Replacement Therapy 

[RRT]) and documented 

proteinuria with a blood 

pressure < 130/80 mmHg 

OR ≥ 130/80 mmHg with 

a documented plan of care 

AMAPCPI 

X X X 

AQA 

adopt

ed/ 

 Clinical 

Process/ 

Effectivenes

Adult Kidney Disease: 

Patients On 

ErythropoiesisAMAPCPI 

X X X 
CMS-1590-P 401 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

123 s 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 ESA 

therapy AND have a 

Hemoglobin level > 12.0 

g/dL 

0417/ 

126 

 Clinical 

Process/ 

Effectivenes

s 

Diabetes Mellitus: 

Diabetic Foot and Ankle 

Care, Peripheral 

Neuropathy – 

Neurological Evaluation: 

Percentage of patients 

aged 18 years and older 

with a diagnosis of 

diabetes mellitus who had 

a neurological 

examination of their lower 

extremities within 12 

months 

APMA X X 

0416/ 

127 

 Clinical 

Process/ 

Diabetes Mellitus: 

Diabetic Foot and Ankle 

APMA X X 
CMS-1590-P 402 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

Effectivenes

s 

Care, Ulcer Prevention – 

Evaluation of Footwear: 

Percentage of patients 

aged 18 years and older 

with a diagnosis of 

diabetes mellitus who 

were evaluated for proper 

footwear and sizing 

0421/ 

128 

 Population/

Public 

Health 

Preventive Care and 

Screening: Body Mass 

Index (BMI) Screening 

and Follow-Up: 

Percentage of patients 

aged 18 years and older 

with a calculated BMI in 

the past six months or 

during the current visit 

documented in the 

medical record AND if the 

most recent BMI is 

outside of normal

parameters, a follow-up 

plan is documented. 

Normal Parameters: Age 

65 years and older BMI ≥

23 and < 30; Age 18 – 64 

years BMI ≥ 18.5 and < 

25. 

CMS/ 

QIP 

X X X X X HITE

CH 

ACO 

0419/ 

130 

 Patient 

Safety 

Documentation of 

Current Medications in 

the Medical Record: 

Percentage of specified 

visits for patients aged 18 

years and older for which 

the eligible professional 

attests to documenting a 

CMS/ 

QIP 

X X X HITE

CH 

 
CMS-1590-P 403 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

list of current medications 

to the best of his/her 

knowledge and ability. 

This list must include 

ALL prescriptions, overthe-counters, herbals, 

vitamin/mineral/dietary 

(nutritional) supplements 

AND must contain the 

medications’ name, 

dosage, frequency and 

route 

0420/ 

131 

 Population/

Public 

Health 

Pain Assessment and 

Follow-Up: Percentage of 

patients aged 18 years and 

older with documentation 

of a pain assessment 

through discussion with 

the patient including the 

use of a standardized 

tool(s) on each visit AND 

documentation of a 

follow-up plan when pain 

is present 

CMS/ 

QIP 

X X 

0418/ 

134 

 Population/

Public 

Health 

Preventive Care and 

Screening: Screening for 

Clinical Depression and 

Follow-Up Plan: 

Percentage of patients 

aged 12 years and older 

screened for clinical 

depression using an age 

appropriate standardized 

tool AND follow-up plan 

documented 

CMS/ 

QIP 

X X 

X 

 HITE

CH 

ACO 

0650/ Clinical Melanoma: Continuity AMA- X 
CMS-1590-P 404 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

137 Process/ 

Effectivenes

s 

of Care – Recall System: 

Percentage of patients, 

regardless of age, with a 

current diagnosis of 

melanoma or a history of 

melanoma whose 

information was entered, 

at least once within a 12 

month period, into a recall 

system that includes: 

• A target date for the next 

complete physical skin 

exam, AND 

• A process to follow up 

with patients who either 

did not make an 

appointment within the 

specified timeframe or 

who missed a scheduled 

appointment 

PCPI/ 

NCQA 

0561/ 

138 

 Care 

Coordinatio

n 

Melanoma: 

Coordination of Care: 

Percentage of patient 

visits, regardless of patient 

age, with a new 

occurrence of melanoma 

who have a treatment plan 

documented in the chart 

that was communicated to 

the physician(s) providing 

continuing care within one 

month of diagnosis 

AMAPCPI/ 

NCQA 

 X 

0566/ 

140 

 Clinical 

Process/ 

Effectivenes

s 

Age-Related Macular 

Degeneration (AMD): 

Counseling on 

Antioxidant 

AMAPCPI/ 

NCQA 

X X 
CMS-1590-P 405 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

Supplement: Percentage 

of patients aged 50 years 

and older with a diagnosis 

of AMD and/or their 

caregiver(s) who were 

counseled within 12 

months on the benefits 

and/or risks of the AgeRelated Eye Disease 

Study (AREDS) 

formulation for preventing 

progression of AMD 

0563/ 

141 

 Care 

Coordinatio

n 

Primary Open-Angle 

Glaucoma (POAG): 

Reduction of Intraocular 

Pressure (IOP) by 15% 

OR Documentation of a 

Plan of Care: Percentage 

of patients aged 18 years 

and older with a diagnosis 

of POAG whose 

glaucoma treatment has 

not failed (the most recent 

IOP was reduced by at 

least 15% from the preintervention level) OR if 

the most recent IOP was 

not reduced by at least 

15% from the preintervention level, a plan 

of care was documented 

within 12 months 

AMAPCPI/ 

NCQA 

X X 

0051/ 

142 

 Clinical 

Process/ 

Effectivenes

s 

Osteoarthritis (OA): 

Assessment for Use of 

Anti-Inflammatory or 

Analgesic Over-theAMAPCPI 

X X 
CMS-1590-P 406 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

Counter (OTC) 

Medications: Percentage 

of patient visits for 

patients aged 21 years and 

older with a diagnosis of 

OA with an assessment 

for use of antiinflammatory or analgesic 

OTC medications 

0384/ 

143 

 Patient and 

Family 

Engagement 

Oncology: Medical and 

Radiation – Pain 

Intensity Quantified: 

Percentage of patient 

visits, regardless of patient 

age, with a diagnosis of 

cancer currently receiving 

chemotherapy or radiation 

therapy in which pain 

intensity is quantified 

AMAPCPI  X X HITE

CH 

0383/ 

144 

 Patient and 

Family 

Engagement 

Oncology: Medical and 

Radiation – Plan of Care 

for Pain: Percentage of 

patient visits, regardless of 

patient 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 

AMAPCPI 

 X X 

0510/ 

145 

 Patient 

Safety 

Radiology: Exposure 

Time Reported for 

Procedures Using 

Fluoroscopy: Percentage 

of final reports for 

AMAPCPI/ 

NCQA 

X X 
CMS-1590-P 407 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

procedures using 

fluoroscopy that include 

documentation of 

radiation exposure or 

exposure time 

0508/ 

146 

 Efficient 

Use of 

Healthcare 

Resources 

Radiology: 

Inappropriate Use of 

“Probably Benign” 

Assessment Category in 

Mammography 

Screening: Percentage of 

final reports for screening 

mammograms that are 

classified as “probably 

benign” 

AMAPCPI/ 

NCQA 

X X 

0511/ 

147 

 Care 

Coordinatio

n 

Nuclear Medicine: 

Correlation with 

Existing Imaging Studies 

for All Patients 

Undergoing Bone 

Scintigraphy: Percentage 

of final reports for all 

patients, regardless of age, 

undergoing bone 

scintigraphy that include 

physician documentation 

of correlation with 

existing relevant imaging 

studies (e.g., x-ray, MRI, 

CT, etc.) that were 

performed 

AMAPCPI 

X X 

0322/ 

148 

 Efficient 

Use of 

Healthcare 

Resources 

Back Pain: Initial Visit: 

The percentage of patients 

aged 18 through 79 years 

with a diagnosis of back 

pain or undergoing back 

NCQA X 
CMS-1590-P 408 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

surgery who had back 

pain and function assessed 

during the initial visit to 

the clinician for the 

episode of back pain 

0319/ 

149 

 Clinical 

Process/ 

Effectivenes

s 

Back Pain: Physical 

Exam: Percentage of 

patients aged 18 through 

79 years with a diagnosis 

of back pain or 

undergoing back surgery 

who received a physical 

examination at the initial 

visit to the clinician for 

the episode of back pain 

NCQA X 

0314/ 

150 

 Clinical 

Process/ 

Effectivenes

s 

Back Pain: Advice for 

Normal Activities: The 

percentage of patients 

aged 18 through 79 years 

with a diagnosis of back 

pain or undergoing back 

surgery who received 

advice for normal 

activities at the initial visit 

to the clinician for the 

episode of back pain 

NCQA X 

0313/ 

151 

 Clinical 

Process/ 

Effectivenes

s 

Back Pain: Advice 

Against Bed Rest: The 

percentage of patients 

aged 18 through 79 years 

with a diagnosis of back 

pain or undergoing back 

surgery who received 

advice against bed rest 

lasting four days or longer 

at the initial visit to the 

NCQA X 
CMS-1590-P 409 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

clinician for the episode of 

back pain 

AQA 

adopt

ed/ 

154 

 Patient 

Safety 

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 

AMAPCPI/ 

NCQA 

X X 

AQA 

adopt

ed/ 

155 

 Care 

Coordinatio

n 

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 

AMAPCPI/ 

NCQA 

X X 

0382/ 

156 

 Patient 

Safety 

Oncology: Radiation 

Dose Limits to Normal 

Tissues: Percentage of 

patients, regardless of age, 

with a diagnosis of 

pancreatic or lung cancer 

receiving 3D conformal 

radiation therapy with 

documentation in medical 

record that radiation dose 

limits to normal tissues 

were established prior to 

the initiation of a course 

of 3D conformal radiation 

for a minimum of two 

tissues 

AMAPCPI X X 

0455/ 

157 

 Patient 

Safety 

Thoracic Surgery: 

Recording of Clinical 

Stage Prior to Lung 

Cancer or Esophageal 

STS X X 
CMS-1590-P 410 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

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 

0404/ 

159 

 Clinical 

Process/ 

Effectivenes

s 

HIV/AIDS: CD4+ Cell 

Count or CD4+ 

Percentage: Percentage 

of patients aged 6 months 

and older with a diagnosis 

of HIV/AIDS for whom a 

CD4+ cell count or CD4+ 

cell percentage was 

performed at least once 

every 6 months 

AMAPCPI/ 

NCQA 

 X X 

0405/ 

160 

 Clinical 

Process/ 

Effectivenes

s 

HIV/AIDS: 

Pneumocystis Jiroveci 

Pneumonia (PCP) 

Prophylaxis: Percentage 

of patients aged 6 years 

and older with a diagnosis 

of HIV/AIDS and CD4+ 

cell count < 200 

cells/mm3 who were 

prescribed PCP 

prophylaxis within 3 

months of low CD4+ cell 

count 

AMAPCPI/ 

NCQA 

 X X HITE

CH 

0406/ 

161 

 Clinical 

Process/ 

Effectivenes

s 

HIV/AIDS: Adolescent 

and Adult Patients with 

HIV/AIDS Who Are 

Prescribed Potent 

Antiretroviral Therapy: 

AMAPCPI/ 

NCQA 

 X X 
CMS-1590-P 411 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

Percentage of patients 

with a diagnosis of 

HIV/AIDS aged 13 years 

and older: who have a 

history of a nadir CD4+ 

cell count below 350/mm3 

or who have a history of 

an AIDS- defining 

condition, regardless of 

CD4+ cell count; or who 

are pregnant, regardless of 

CD4+ cell count or age, 

who were prescribed 

potent antiretroviral 

therapy 

0407/ 

162 

 Clinical 

Process/ 

Effectivenes

s 

HIV/AIDS: HIV RNA 

Control After Six 

Months of Potent 

Antiretroviral Therapy: 

Percentage of patients 

aged 13 years and older 

with a diagnosis of 

HIV/AIDS who are 

receiving potent 

antiretroviral therapy, who 

have a viral load below 

limits of quantification 

after at least 6 months of 

potent antiretroviral 

therapy or patients whose 

viral load is not below 

limits of quantification 

after at least 6 months of 

potent antiretroviral 

therapy and have 

documentation of a plan 

AMAPCPI/ 

NCQA 

 X X HITE

CH 
CMS-1590-P 412 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

of care 

0056/ 

163 

 Clinical 

Process/ 

Effectivenes

s 

Diabetes Mellitus: Foot 

Exam: The percentage of 

patients aged 18 through 

75 years with diabetes 

who had a foot 

examination 

NCQA X X X X HITE

CH 

0129/ 

164 

 Clinical 

Process/ 

Effectivenes

s 

Coronary Artery Bypass 

Graft (CABG): 

Prolonged Intubation: 

Percentage of patients 

aged 18 years and older 

undergoing isolated 

CABG surgery who 

require intubation > 24 

hours 

STS X X 

0130/ 

165 

 Clinical 

Process/ 

Effectivenes

s 

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 X X 

0131/ 

166 

 Clinical 

Process/ 

Effectivenes

s 

Coronary Artery Bypass 

Graft (CABG): Stroke: 

Percentage of patients 

aged 18 years and older 

undergoing isolated 

CABG surgery who have 

STS X X 
CMS-1590-P 413 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

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 

0114/ 

167 

 Clinical 

Process/ 

Effectivenes

s 

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 X X 

0115/ 

168 

 Clinical 

Process/ 

Effectivenes

s 

Coronary Artery Bypass 

Graft (CABG): Surgical 

Re-Exploration: 

Percentage of patients 

aged 18 years and older 

undergoing isolated 

CABG surgery who 

require a return to the 

operating room (OR) 

during the current 

hospitalization for 

mediastinal bleeding with 

or without tamponade, 

graft occlusion, valve 

dysfunction, or other 

cardiac reason 

STS X X 

0116/ Clinical Coronary Artery Bypass STS X X 
CMS-1590-P 414 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

169 Process/ 

Effectivenes

s 

Graft (CABG): 

Antiplatelet Medications 

at Discharge: 

Percentage of patients 

aged 18 years and older 

undergoing isolated 

CABG surgery who were 

discharged on antiplatelet 

medication 

0117/ 

170 

 Clinical 

Process/ 

Effectivenes

s 

Coronary Artery Bypass 

Graft (CABG): BetaBlockers Administered 

at Discharge: Percentage 

of patients aged 18 years 

and older undergoing 

isolated CABG surgery 

who were discharged on 

beta-blockers 

STS X X 

0118/ 

171 

 Clinical 

Process/ 

Effectivenes

s 

Coronary Artery Bypass 

Graft (CABG): AntiLipid Treatment at 

Discharge: Percentage of 

patients aged 18 years and 

older undergoing isolated 

CABG surgery who were 

discharged on a statin or 

other lipid-lowering 

regimen 

STS X X 

0259/ 

172 

 Clinical 

Process/ 

Effectivenes

s 

Hemodialysis Vascular 

Access Decision-Making 

by Surgeon to Maximize 

Placement of 

Autogenous Arterial 

Venous (AV) Fistula: 

Percentage of patients 

aged 18 years and older 

SVS X X 
CMS-1590-P 415 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

with a diagnosis of 

advanced Chronic Kidney 

Disease (CKD) (stage 4 or 

5) or End Stage Renal 

Disease (ESRD) requiring 

hemodialysis vascular 

access documented by 

surgeon to have received 

autogenous AV fistula 

AQA 

adopt

ed/ 

173 

 Population/

Public 

Health 

Preventive Care and 

Screening: Unhealthy 

Alcohol Use – Screening: 

Percentage of patients 

aged 18 years and older 

who were screened for 

unhealthy alcohol use 

using a systematic 

screening method within 

24 months 

AMAPCPI X X X X 

AQA 

adopt

ed/ 

176 

 Clinical 

Process/ 

Effectivenes

s 

Rheumatoid Arthritis 

(RA): Tuberculosis 

Screening: Percentage of 

patients aged 18 years and 

older with a diagnosis of 

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)

AMAPCPI/ 

NCQA 

X X X 

AQA 

adopt

 Clinical 

Process/ 

Rheumatoid Arthritis 

(RA): Periodic 

AMAPCPI/ 

X X X 
CMS-1590-P 416 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

ed/ 

177 

Effectivenes

s 

Assessment of Disease 

Activity: Percentage of 

patients aged 18 years and 

older with a diagnosis of 

RA who have an 

assessment and 

classification of disease 

activity within 12 months 

NCQA 

AQA 

adopt

ed/ 

178 

 Clinical 

Process/ 

Effectivenes

s 

Rheumatoid Arthritis 

(RA): Functional Status 

Assessment: Percentage 

of patients aged 18 years 

and older with a diagnosis 

of RA for whom a 

functional status 

assessment was performed 

at least once within 12 

months 

AMAPCPI/ 

NCQA 

X X X 

AQA 

adopt

ed/ 

179 

 Clinical 

Process/ 

Effectivenes

s 

Rheumatoid Arthritis 

(RA): Assessment and 

Classification of Disease 

Prognosis: Percentage of 

patients aged 18 years and 

older with a diagnosis of 

RA who have an 

assessment and 

classification of disease 

prognosis at least once 

within 12 months 

AMAPCPI/ 

NCQA 

X X X 

AQA 

adopt

ed/ 

180 

 Care 

Coordinatio

n 

Rheumatoid Arthritis 

(RA): Glucocorticoid 

Management: Percentage 

of patients aged 18 years 

and older with a diagnosis 

of RA who have been 

assessed for 

AMAPCPI/ 

NCQA 

X X X 
CMS-1590-P 417 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

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 

AQA 

adopt

ed/ 

181 

 Patient 

Safety 

Elder Maltreatment 

Screen and Follow-Up 

Plan: Percentage of 

patients aged 65 years and 

older with documentation 

of a screen for elder 

maltreatment AND 

documented follow-up 

plan 

CMS/ 

QIP 

X X 

AQA 

adopt

ed/ 

182 

 Care 

Coordinatio

n 

Functional Outcome 

Assessment: Percentage 

of patients aged 18 years 

and older with 

documentation of a 

current functional 

outcome assessment using 

a standardized functional 

outcome assessment tool 

AND documentation of a 

care plan based on 

identified functional 

outcome deficiencies 

CMS/ 

QIP 

X X 

0399/ 

183 

 Population/

Public 

Health 

Hepatitis C: Hepatitis A 

Vaccination in Patients 

with HCV: Percentage of 

patients aged 18 years and 

AMAPCPI 

X X X 
CMS-1590-P 418 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

older with a diagnosis of 

hepatitis C who received 

at least one injection of 

hepatitis A vaccine, or 

who have documented 

immunity to hepatitis A 

0400/ 

184 

 Population/

Public 

Health 

Hepatitis C: Hepatitis B 

Vaccination in Patients 

with HCV: Percentage of 

patients aged 18 years and 

older with a diagnosis of 

hepatitis C who received 

at least one injection of 

hepatitis B vaccine, or 

who have documented 

immunity to hepatitis B 

AMAPCPI X X X 

0659/ 

185 

 Care 

Coordinatio

n 

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 colonic polyp(s) 

in a previous colonoscopy, 

who had a follow-up 

interval of 3 or more years 

since their last 

colonoscopy documented 

in the colonoscopy report 

AMAPCPI/ 

NCQA 

X X 

0437/ 

187 

 Clinical 

Process/ 

Stroke and Stroke 

Rehabilitation: 

AHA/ 

ASA/ TJC

 X 
CMS-1590-P 419 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

Effectivenes

s 

Thrombolytic Therapy: 

Percentage of patients 

aged 18 years and older 

with a diagnosis of acute 

ischemic stroke who 

arrive at the hospital 

within two hours of time 

last known well and for 

whom IV t-PA was 

initiated within three 

hours of time last known 

well 

N/A/ 

188 

 Care 

Coordinatio

n 

Referral for Otologic 

Evaluation for Patients 

with Congenital or 

Traumatic Deformity of 

the Ear: Percentage of 

patients aged birth and 

older referred to a 

physician (preferably a 

physician with training in 

disorders of the ear) for an 

otologic evaluation 

subsequent to an 

audiologic evaluation after 

presenting with a 

congenital or traumatic 

deformity of the ear 

(internal or external) 

AQC X X 

0565/ 

191 

 Clinical 

Process/ 

Effectivenes

s 

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 

AMAPCPI/ 

NCQA 

 X X HITE

CH 
CMS-1590-P 420 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

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 

0564/ 

192 

 Patient 

Safety 

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 

AMAPCPI/ 

NCQA 

 X X HITE

CH 

0454/ 

193 

 Patient 

Safety 

Perioperative 

Temperature 

AMAPCPI 

X X 
CMS-1590-P 421 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

Management: Percentage 

of patients, regardless of 

age, undergoing surgical 

or therapeutic procedures 

under general or neuraxial 

anesthesia of 60 minutes 

duration or longer, except 

patients undergoing 

cardiopulmonary bypass, 

for whom either active 

warming was used 

intraoperatively for the 

purpose of maintaining 

normothermia, OR at least 

one body temperature 

equal to or greater than 36 

degrees Centigrade (or 

96.8 degrees Fahrenheit) 

was recorded within the 

30 minutes immediately 

before or the 15 minutes 

immediately after 

anesthesia end time 

0386/ 

194 

 Clinical 

Process/ 

Effectivenes

s 

Oncology: Cancer Stage 

Documented: Percentage 

of patients, regardless of 

age, with a diagnosis of 

breast, colon, or rectal 

cancer who are seen in the 

ambulatory setting who 

have a baseline AJCC 

cancer stage or 

documentation that the 

cancer is metastatic in the 

medical record at least 

once within 12 months 

AMAPCPI/ 

ASCO 

X X X 
CMS-1590-P 422 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

0507/ 

195 

 Clinical 

Process/ 

Effectivenes

s 

Radiology: Stenosis 

Measurement in Carotid 

Imaging Reports: 

Percentage of final reports 

for all patients, regardless 

of age, for carotid imaging 

studies (neck magnetic 

resonance angiography 

[MRA], neck computed 

tomography angiography 

[CTA], neck duplex 

ultrasound, carotid 

angiogram) performed 

that include direct or 

indirect reference to 

measurements of distal 

internal carotid diameter 

as the denominator for 

stenosis measurement 

AMAPCPI/ 

NCQA 

X X 

0074/ 

197 

 Clinical 

Process/ 

Effectivenes

s 

Coronary Artery Disease 

(CAD): Lipid Control: 

Percentage of patients 

aged 18 years and older 

with a diagnosis of 

coronary artery disease 

seen within a 12 month 

period who have a LDL-C 

result < 100 mg/dL OR 

patients who have a LDLC result ≥ 100 mg/dL and 

have a documented plan 

of care to achieve LDL-C 

<100 mg/dL, including at 

a minimum the 

prescription of a statin 

AMAPCPI/ 

ACCF/A

HA 

 X X X X ACO 

0079/ Clinical Heart Failure: Left AMA- X X 
CMS-1590-P 423 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

198 Process/ 

Effectivenes

s 

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 result (of a 

recent or prior [any time 

in the past] LVEF 

assessment) is 

documented within a 12 

month period 

PCPI/ 

ACCF/A

HA 

0084/ 

200 

 Clinical 

Process/ 

Effectivenes

s 

Heart Failure: Warfarin 

Therapy for Patients 

with Atrial Fibrillation: 

Percentage of all patients 

aged 18 and older with a 

diagnosis of heart failure 

and paroxysmal or chronic 

atrial fibrillation who 

were prescribed warfarin 

therapy 

AMAPCPI/ 

ACCF/A 

HA 

 X 

0073/ 

201 

 Clinical 

Process/ 

Effectivenes

s 

Ischemic Vascular 

Disease (IVD): Blood 

Pressure Management 

Control: Percentage of 

patients aged 18 years and 

older with ischemic 

vascular disease (IVD) 

who had most recent 

blood pressure in control 

(less than 140/90 mmHg) 

NCQA X X X X HITE

CH 

0068/ 

204 

 Clinical 

Process/ 

Effectivenes

Ischemic Vascular 

Disease (IVD): Use of 

Aspirin or Another 

NCQA X X X X X HITE

CH 

ACO 
CMS-1590-P 424 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

s Antithrombotic: 

Percentage of patients 

aged 18 years and older 

with ischemic vascular 

disease (IVD) with 

documented use of aspirin 

or other antithrombotic 

Millio

n 

Hearts 

0409/ 

205 

 Clinical 

Process/ 

Effectivenes

s 

HIV/AIDS: Sexually 

Transmitted Disease 

Screening for Chlamydia 

and Gonorrhea: 

Percentage of patients 

aged 13 years and older 

with a diagnosis of 

HIV/AIDS for whom 

chlamydia and gonorrhea 

screenings were 

performed at least once 

since the diagnosis of HIV 

infection 

AMAPCPI/ 

NCQA 

 X X 

0413/ 

206 

 Clinical 

Process/ 

Effectivenes

s 

HIV/AIDS: Screening 

for High Risk Sexual 

Behaviors: Percentage of 

patients aged 13 years and 

older with a diagnosis of 

HIV/AIDS who were 

screened for high risk 

sexual behaviors at least 

once within 12 months 

AMAPCPI/ 

NCQA 

 X X 

0415/ 

207 

 Clinical 

Process/ 

Effectivenes

s 

HIV/AIDS: Screening 

for Injection Drug Use: 

Percentage of patients 

aged 13 years and older 

with a diagnosis of 

HIV/AIDS who were 

screened for injection 

AMAPCPI/ 

NCQA 

 X X 
CMS-1590-P 425 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

drug use at least once 

within 12 months 

0410/ 

208 

 Clinical 

Process/ 

Effectivenes

s 

HIV/AIDS: Sexually 

Transmitted Disease 

Screening for Syphilis: 

Percentage of patients 

aged 13 years and older 

with a diagnosis of 

HIV/AIDS who were 

screened for syphilis at 

least once within 12 

months 

AMAPCPI/ 

NCQA 

 X X 

0445/ 

209 

 Care 

Coordinatio

n 

Functional 

Communication 

Measure - Spoken 

Language 

Comprehension: 

Percentage of patients 

aged 16 years and older 

with a diagnosis of late 

effects of cerebrovascular 

disease (CVD) that make 

progress on the Spoken 

Language Comprehension 

Functional 

Communication Measure 

ASHA X 

0449/ 

210 

 Care 

Coordinatio

n 

Functional 

Communication 

Measure – Attention: 

Percentage of patients 

aged 16 years and older 

with a diagnosis of late 

effects of cerebrovascular 

disease (CVD) that make 

progress on the Attention 

Functional 

ASHA X 
CMS-1590-P 426 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

Communication Measure 

0448/ 

211 

 Care 

Coordinatio

n 

Functional 

Communication 

Measure – Memory: 

Percentage of patients 

aged 16 years and older 

with a diagnosis of late 

effects of cerebrovascular 

disease (CVD) that make 

progress on the Memory 

Functional 

Communication Measure 

ASHA X 

0446/ 

213 

 Care 

Coordinatio

n 

Functional 

Communication 

Measure – Reading: 

Percentage of patients 

aged 16 years and older 

with a diagnosis of late 

effects of cerebrovascular 

disease (CVD) that make 

progress on the Reading 

Functional 

Communication Measure 

ASHA X 

0444/ 

214 

 Care 

Coordinatio

n 

Functional 

Communication 

Measure - Spoken 

Language Expression: 

Percentage of patients 

aged 16 years and older 

with a diagnosis of late 

effects of cerebrovascular 

disease (CVD) that make 

progress on the Spoken 

Language Expression 

Functional 

Communication Measure 

ASHA X 
CMS-1590-P 427 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

0442/ 

215 

 Care 

Coordinatio

n 

Functional 

Communication 

Measure – Writing: 

Percentage of patients 

aged 16 years and older 

with a diagnosis of late 

effects of cerebrovascular 

disease (CVD) that make 

progress on the Writing 

Functional 

Communication Measure 

ASHA X 

0443/ 

216 

 Care 

Coordinatio

n 

Functional 

Communication 

Measure – Swallowing: 

Percentage of patients 

aged 16 years and older 

with a diagnosis of late 

effects of cerebrovascular 

disease (CVD) that make 

progress on the 

Swallowing Functional 

Communication Measure 

ASHA X 

0422/ 

217 

 Care 

Coordinatio

n 

Functional Deficit: 

Change in RiskAdjusted Functional 

Status for Patients with 

Knee Impairments: 

Percentage of patients 

aged 18 or older that 

receive treatment for a 

functional deficit 

secondary to a diagnosis 

that affects the knee in 

which the change in their 

Risk-Adjusted Functional 

Status is measured 

FOTO X 
CMS-1590-P 428 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

0423/ 

218 

 Care 

Coordinatio

n 

Functional Deficit: 

Change in RiskAdjusted Functional 

Status for Patients with 

Hip Impairments: 

Percentage of patients 

aged 18 or older that 

receive treatment for a 

functional deficit 

secondary to a diagnosis 

that affects the hip in 

which the change in their 

Risk-Adjusted Functional 

Status is measured 

FOTO X 

0424/ 

219 

 Care 

Coordinatio

n 

Functional Deficit: 

Change in RiskAdjusted Functional 

Status for Patients with 

Lower Leg, Foot or 

Ankle Impairments: 

Percentage of patients 

aged 18 or older that 

receive treatment for a 

functional deficit 

secondary to a diagnosis 

that affects the lower leg, 

foot or ankle in which the 

change in their RiskAdjusted Functional 

Status is measured 

FOTO X 

0425/ 

220 

 Care 

Coordinatio

n 

Functional Deficit: 

Change in RiskAdjusted Functional 

Status for Patients with 

Lumbar Spine 

Impairments: Percentage 

FOTO X 
CMS-1590-P 429 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

of patients aged 18 or 

older that receive 

treatment for a functional 

deficit secondary to a 

diagnosis that affects the 

lumbar spine in which the 

change in their RiskAdjusted Functional 

Status is measured 

0426/ 

221 

 Care 

Coordinatio

n 

Functional Deficit: 

Change in RiskAdjusted Functional 

Status for Patients with 

Shoulder Impairments: 

Percentage of patients 

aged 18 or older that 

receive treatment for a 

functional deficit 

secondary to a diagnosis 

that affects the shoulder in 

which the change in their 

Risk- Adjusted Functional 

Status is measured 

FOTO X 

0427/ 

222 

 Care 

Coordinatio

n 

Functional Deficit: 

Change in RiskAdjusted Functional 

Status for Patients with 

Elbow, Wrist or Hand 

Impairments: Percentage 

of patients aged 18 or 

older that receive 

treatment for a functional 

deficit secondary to a 

diagnosis that affects the 

elbow, wrist or hand in 

which the change in their 

FOTO X 
CMS-1590-P 430 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

Risk-Adjusted Functional 

Status is measured 

0428/ 

223 

 Care 

Coordinatio

n 

Functional Deficit: 

Change in RiskAdjusted Functional 

Status for Patients with 

Neck, Cranium, 

Mandible, Thoracic 

Spine, Ribs, or Other 

General Orthopedic 

Impairments: 

Percentage of patients 

aged 18 or older that 

receive treatment for a 

functional deficit 

secondary to a diagnosis 

that affects the neck, 

cranium, mandible, 

thoracic spine, ribs, or 

other general orthopedic 

impairment in which the 

change in their RiskAdjusted Functional 

Status is measured 

FOTO X 

0562/ 

224 

 Efficient 

Use of 

Healthcare 

Resources 

Melanoma: 

Overutilization of 

Imaging Studies in 

Melanoma: Percentage of 

patients, regardless of age, 

with a current diagnosis of 

melanoma or a history of 

melanoma, without signs 

or symptoms, seen for an 

office visit during the oneyear measurement period, 

for whom no diagnostic 

AMAPCPI/ 

NCQA 

 X 
CMS-1590-P 431 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

imaging studies were 

ordered 

0509/ 

225 

 Care 

Coordinatio

n 

Radiology: Reminder 

System for 

Mammograms: 

Percentage of patients 

aged 40 years and older 

undergoing a screening 

mammogram whose 

information is entered into 

a reminder system with a 

target due date for the 

next mammogram 

AMAPCPI/ 

NCQA 

X X 

0028/ 

226 

 Population/

Public 

Health 

Preventive Care and 

Screening: Tobacco Use: 

Screening and Cessation 

Intervention: Percentage 

of patients aged 18 years 

and older who were 

screened for tobacco use 

one or more times within 

24 months AND who 

received cessation 

counseling intervention if 

identified as a tobacco 

user 

AMAPCPI 

X X X X X HITE

CH 

ACO 

Millio

n 

Hearts 

N/A/ 

228 

 Clinical 

Process/ 

Effectivenes

s 

Heart Failure (HF): Left 

Ventricular Function 

(LVF) Testing: 

Percentage of patients 18 

years and older with LVF 

testing performed during 

the measurement period 

for patients hospitalized 

with a principal diagnosis 

of HF during the reporting 

CMS/ 

QIP 

 X 
CMS-1590-P 432 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

period 

N/A/ 

231 

 Clinical 

Process/ 

Effectivenes

s 

Asthma: Tobacco Use: 

Screening - Ambulatory 

Care Setting: Percentage 

of patients (or their 

primary caregiver) aged 5 

through 50 years with a 

diagnosis of asthma 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 

AMAPCPI/ 

NCQA 

X X X 

N/A/ 

232 

 Clinical 

Process/ 

Effectivenes

s 

Asthma: Tobacco Use: 

Intervention - 

Ambulatory Care 

Setting: Percentage of 

patients (or their primary 

caregiver) aged 5 through 

50 years with a diagnosis 

of asthma who were 

identified as tobacco users 

(patients who currently 

use tobacco AND patients 

who do not currently use 

tobacco, but are exposed 

to second hand smoke in 

their home environment) 

who received tobacco 

cessation intervention at 

least once during the oneyear measurement period 

AMAPCPI/ 

NCQA 

X X X 

0457/ 

233 

 Clinical 

Process/ 

Thoracic Surgery: 

Recording of 

STS X 
CMS-1590-P 433 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

Effectivenes

s 

Performance Status 

Prior to Lung or 

Esophageal Cancer 

Resection: Percentage of 

patients aged 18 years and 

older undergoing resection 

for lung or esophageal 

cancer who had 

performance status 

documented and reviewed 

within 2 weeks prior to 

surgery 

0458/ 

234 

 Patient 

Safety 

Thoracic Surgery: 

Pulmonary Function 

Tests Before Major 

Anatomic Lung 

Resection 

(Pneumonectomy, 

Lobectomy, or Formal 

Segmentectomy): 

Percentage of thoracic 

surgical patients aged 18 

years and older 

undergoing at least one 

pulmonary function test 

within 12 months prior to 

a major lung resection 

(pneumonectomy, 

lobectomy, or formal 

segmentectomy) 

STS X 

0018/ 

236 

 Clinical 

Process/ 

Effectivenes

s 

Hypertension (HTN): 

Controlling High Blood 

Pressure: Percentage of 

patients aged 18 through 

85 years of age who had a 

diagnosis of hypertension 

NCQA X X X X X HITE

CH 

ACO 

Millio

n 

Hearts 
CMS-1590-P 434 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

(HTN) and whose BP was 

adequately controlled (< 

140/90 mmHg) 

0013/ 

237 

 Clinical 

Process/ 

Effectivenes

s 

Hypertension (HTN): 

Blood Pressure 

Measurement: 

Percentage of patient 

visits for patients aged 18 

years and older with a 

diagnosis of HTN with 

blood pressure (BP) 

recorded 

AMAPCPI 

 X 

0022/ 

238 

 Patient 

Safety 

Drugs to be Avoided in 

the Elderly: Percentage 

of patients ages 65 years 

and older who received at 

least one drug to be 

avoided in the elderly 

and/or two different drugs 

to be avoided in the 

elderly in the 

measurement period 

NCQA X HITE

CH 

0024/ 

239 

 Population/

Public 

Health 

Weight Assessment and 

Counseling for Children 

and Adolescents: 

Percentage of children 2 

through 17 years of age 

who had an outpatient 

visit with a PCP or 

OB/GYN and who had 

evidence of BMI 

percentile documentation, 

counseling for nutrition 

and counseling for 

physical activity during 

the measurement period 

NCQA X HITE

CH 
CMS-1590-P 435 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

0038/ 

240 

 Population/

Public 

Health 

Childhood 

Immunization Status: 

The percentage of 

children two years of age 

who had four diphtheria, 

tetanus and acellular 

pertussis (DTaP); three 

polio (IPV); one measles, 

mumps, rubella (MMR); 

three H influenza type B 

(HiB); three hepatitis B 

(Hep B); one chicken pox 

(VZV); four 

pneumococcal conjugate 

(PCV); two hepatitis A 

(Hep A); two or three 

rotavirus (RV); and two 

influenza (flu) vaccines by 

their second birthday 

NCQA X HITE

CH 

0075/ 

241 

 Clinical 

Process/ 

Effectivenes

s 

Ischemic Vascular 

Disease (IVD): Complete 

Lipid Panel and Low 

Density Lipoprotein 

(LDL-C) Control: 

Percentage of patients 

aged 18 years and older 

with Ischemic Vascular 

Disease (IVD) who 

received at least one lipid 

profile within 12 months 

and whose most recent 

LDL-C level was in 

control (less than 100 

mg/dL) 

NCQA X X X X X HITE

CH 

ACO 

Millio

n 

Hearts 

N/A/ 

242 

 Clinical 

Process/ 

Coronary Artery Disease 

(CAD): Symptom 

AMAPCPI/ 

 X X 
CMS-1590-P 436 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

Effectivenes

s 

Management: Percentage 

of patients aged 18 years 

and older with a diagnosis 

of coronary artery disease 

seen within a 12-month 

period and with results of 

an evaluation of level of 

activity AND an 

assessment for the 

presence or absence of 

anginal symptoms, with a 

plan of care to manage 

anginal symptoms, if 

present 

ACCF/A

HA 

0643/ 

243 

 Clinical 

Process/ 

Effectivenes

s 

Cardiac Rehabilitation 

Patient Referral from an 

Outpatient Setting: 

Percentage of patients 

evaluated in an outpatient 

setting who within the 

past 12 months have 

experienced an acute 

myocardial infarction 

(MI), coronary artery 

bypass graft (CABG) 

surgery, a percutaneous 

coronary intervention 

(PCI), cardiac valve 

surgery, or cardiac 

transplantation, or who 

have chronic stable angina 

(CSA) and have not 

already participated in an 

early outpatient cardiac 

rehabilitation/secondary 

prevention (CR) program 

ACCFAHA  X 
CMS-1590-P 437 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

for the qualifying 

event/diagnosis who were 

referred to a CR program 

N/A/ 

244 

 Clinical 

Process/ 

Effectivenes

s 

Hypertension: Blood 

Pressure Management: 

Percentage of patients 

aged 18 years and older 

with a diagnosis of 

hypertension seen within a 

12 month period with a 

blood pressure < 140/90 

mmHg OR patients with a 

blood pressure ≥ 140/90 

mmHg and prescribed two 

or more anti-hypertensive 

medications during the 

most recent office visit 

AMAPCPI/ 

ACCF/A

HA 

 X 

AQA 

adopt

ed/ 

245 

 Clinical 

Process/ 

Effectivenes

s 

Chronic Wound Care: 

Use of Wound Surface 

Culture Technique in 

Patients with Chronic 

Skin Ulcers: Percentage 

of patient visits for those 

patients aged 18 years and 

older with a diagnosis of 

chronic skin ulcer without

the use of a wound surface 

culture technique 

AMAPCPI/ 

NCQA 

X X 

AQA 

adopt

ed/ 

246 

 Clinical 

Process/ 

Effectivenes

s 

Chronic Wound Care: 

Use of Wet to Dry 

Dressings in Patients 

with Chronic Skin 

Ulcers: Percentage of 

patient visits for those 

patients aged 18 years and 

older with a diagnosis of 

AMAPCPI/ 

NCQA 

X X 
CMS-1590-P 438 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

chronic skin ulcer without

a prescription or 

recommendation to use 

wet to dry dressings 

AQA 

adopt

ed/ 

247 

 Clinical 

Process/ 

Effectivenes

s 

Substance Use 

Disorders: Counseling 

Regarding Psychosocial 

and Pharmacologic 

Treatment Options for 

Alcohol Dependence: 

Percentage of patients 

aged 18 years and older 

with a diagnosis of current 

alcohol dependence who 

were counseled regarding 

psychosocial AND 

pharmacologic treatment 

options for alcohol 

dependence within the 12-

month reporting period 

AMAPCPI/ 

NCQA 

X X 

AQA 

adopt

ed/ 

248 

 Clinical 

Process/ 

Effectivenes

s 

Substance Use 

Disorders: Screening for 

Depression Among 

Patients with Substance 

Abuse or Dependence: 

Percentage of patients 

aged 18 years and older 

with a diagnosis of current 

substance abuse or 

dependence who were 

screened for depression 

within the 12-month 

reporting period 

AMAPCPI/ 

NCQA 

X X 

N/A/ 

249 

 Clinical 

Process/ 

Effectivenes

Barrett's Esophagus: 

Percentage of esophageal 

biopsy reports that 

CAP X X 
CMS-1590-P 439 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

s document the presence of 

Barrett’s mucosa that also 

include a statement about 

dysplasia 

N/A/ 

250 

 Clinical 

Process/ 

Effectivenes

s 

Radical Prostatectomy 

Pathology Reporting: 

Percentage of radical 

prostatectomy pathology 

reports that include the pT 

category, the pN category, 

the Gleason score and a 

statement about margin 

status 

CAP X X 

N/A/ 

251 

 Clinical 

Process/ 

Effectivenes

s 

Immunohistochemical 

(IHC) Evaluation of 

Human Epidermal 

Growth Factor Receptor 

2 Testing (HER2) for 

Breast Cancer Patients: 

This is a measure based 

on whether quantitative 

evaluation of Human 

Epidermal Growth Factor 

Receptor 2 Testing 

(HER2) by 

immunohistochemistry 

(IHC) uses the system 

recommended in the 

ASCO/CAP Guidelines 

for Human Epidermal 

Growth Factor Receptor 2 

Testing in breast cancer 

CAP X X 

0503/ 

252 

 Clinical 

Process/ 

Effectivenes

s 

Anticoagulation for 

Acute Pulmonary 

Embolus Patients: 

Anticoagulation ordered 

ACEP X X 
CMS-1590-P 440 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

for patients who have 

been discharged from the 

emergency department 

(ED) with a diagnosis of 

acute pulmonary embolus 

0651/ 

254 

 Clinical 

Process/ 

Effectivenes

s 

Ultrasound 

Determination of 

Pregnancy Location for 

Pregnant Patients with 

Abdominal Pain: 

Percentage of pregnant 

female patients aged 14 to 

50 who present to the 

emergency department 

(ED) with a chief 

complaint of abdominal 

pain or vaginal bleeding 

who receive a transabdominal or transvaginal ultrasound to 

determine pregnancy 

location 

ACEP X X 

0652/ 

255 

 Clinical 

Process/ 

Effectivenes

s 

Rh Immunoglobulin 

(Rhogam) for RhNegative 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 RhImmunoglobulin 

(Rhogam) in the 

emergency department 

(ED) 

ACEP X X 
CMS-1590-P 441 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

N/A/ 

256 

 Care 

Coordinatio

n 

Surveillance after 

Endovascular 

Abdominal Aortic 

Aneurysm Repair 

(EVAR): Percentage of 

patients 18 years of age or 

older undergoing 

endovascular abdominal 

aortic aneurysm repair 

(EVAR) who have at least 

one follow-up imaging 

study after 3 months and 

within 15 months of 

EVAR placement that 

documents aneurysm sac 

diameter and endoleak 

status 

SVS X 

N/A/ 

257 

 Clinical 

Process/ 

Effectivenes

s 

Statin Therapy at 

Discharge after Lower 

Extremity Bypass 

(LEB): Percentage of 

patients aged 18 years and 

older undergoing infrainguinal lower extremity 

bypass who are prescribed 

a statin medication at 

discharge 

SVS X 

N/A/ 

258 

 Care 

Coordinatio

n 

Rate of Open Elective 

Repair of Small or 

Moderate Abdominal 

Aortic Aneurysms 

(AAA) without Major 

Complications 

(Discharged to Home by 

Post-Operative Day #7): 

Percent of patients 

SVS X 
CMS-1590-P 442 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

undergoing open repair of 

small or moderate sized 

abdominal aortic 

aneurysms who do not 

experience a major 

complication (discharge to 

home no later than postoperative day #7) 

N/A/ 

259 

 Care 

Coordinatio

n 

Rate of Elective 

Endovascular Aortic 

Repair (EVAR) of Small 

or Moderate Abdominal 

Aortic Aneurysms 

(AAA) without Major 

Complications 

(Discharged to Home by 

Post- Operative Day #2): 

Percent of patients 

undergoing endovascular 

repair of small or 

moderate abdominal aortic 

aneurysms (AAA) that do 

not experience a major 

complication (discharged 

to home no later than 

post-operative day #2) 

SVS X 

N/A/ 

260 

 Care 

Coordinatio

n 

Rate of Carotid 

Endarterectomy (CEA) 

for Asymptomatic 

Patients, without Major 

Complications 

(Discharged to Home 

Post-Operative Day #2): 

Percent of asymptomatic 

patients undergoing CEA 

who are discharged to 

SVS X 
CMS-1590-P 443 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

home no later than postoperative day #2 

N/A/ 

261 

 Care 

Coordinatio

n 

Referral for Otologic 

Evaluation for Patients 

with Acute or Chronic 

Dizziness: Percentage of 

patients aged birth and 

older referred to a 

physician (preferably a 

physician specially trained 

in disorders of the ear) for 

an otologic evaluation 

subsequent to an 

audiologic evaluation after 

presenting with acute or 

chronic dizziness 

AQC X X 

N/A/ 

262 

 Patient 

Safety 

Image Confirmation of 

Successful Excision of 

Image–Localized Breast 

Lesion: Image 

confirmation of lesion(s) 

targeted for image guided 

excisional biopsy or 

image guided partial 

mastectomy in patients 

with nonpalpable, imagedetected breast lesion(s). 

Lesions may include: 

microcalcifications, 

mammographic or 

sonographic mass or 

architectural distortion, 

focal suspicious 

abnormalities on magnetic 

resonance imaging (MRI) 

or other breast imaging 

ASBS X X 
CMS-1590-P 444 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

amenable to localization 

such as positron emission 

tomography (PET) 

mammography, or a 

biopsy marker 

demarcating site of 

confirmed pathology as 

established by previous 

core biopsy. 

N/A/ 

263 

 Clinical 

Process/ 

Effectivenes

s 

Preoperative Diagnosis 

of Breast Cancer: The 

percent of patients 

undergoing breast cancer 

operations who obtained 

the diagnosis of breast 

cancer preoperatively by a 

minimally invasive biopsy 

method (excludes 

open/incisional biopsies) 

ASBS X X 

N/A/ 

264 

 Clinical 

Process/ 

Effectivenes

s 

Sentinel Lymph Node 

Biopsy for Invasive 

Breast Cancer: The 

percentage of clinically 

node negative (clinical 

stage T1N0M0 or 

T2N0M0) breast cancer 

patients who undergo a 

sentinel lymph node 

(SLN) procedure 

ASBS X 

0645/ 

265 

 Care 

Coordinatio

n 

Biopsy Follow-Up: 

Percentage of patients 

whose biopsy results have 

been reviewed and 

communicated to the 

primary care/referring 

physician and patient by 

AAD X 
CMS-1590-P 445 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

the performing physician 

N/A/ 

266 

 Clinical 

Process/ 

Effectivenes

s 

Epilepsy: Seizure 

Type(s) and Current 

Seizure Frequency(ies): 

Percentage of patient 

visits with a diagnosis of 

epilepsy who had the 

type(s) of seizure(s) and 

current seizure 

frequency(ies) for each 

seizure type documented 

in the medical record 

AAN X X 

N/A/ 

267 

 Clinical 

Process/ 

Effectivenes

s 

Epilepsy: 

Documentation of 

Etiology of Epilepsy or 

Epilepsy Syndrome: All 

visits for patients with a 

diagnosis of epilepsy who 

had their etiology of 

epilepsy or with epilepsy 

syndrome(s) reviewed and 

documented if known, or 

documented as unknown 

or cryptogenic 

AAN X X 

N/A/ 

268 

 Clinical 

Process/ 

Effectivenes

s 

Epilepsy: Counseling for 

Women of Childbearing 

Potential with Epilepsy: 

All female patients of 

childbearing potential (12-

44 years old) diagnosed 

with epilepsy who were 

counseled about epilepsy 

and how its treatment may 

affect contraception and 

pregnancy at least once a 

year 

AAN X X 
CMS-1590-P 446 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

N/A/ 

269 

 Clinical 

Process/ 

Effectivenes

s 

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 

AGA X 

N/A/ 

270 

 Clinical 

Process/ 

Effectivenes

s 

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 10mg/day 

for 60 or greater 

consecutive days that have 

been prescribed 

corticosteroid sparing 

therapy in the last 

reporting year 

AGA X 

N/A/ 

271 

 Clinical 

Process/ 

Effectivenes

s 

Inflammatory Bowel 

Disease (IBD): 

Preventive Care: 

Corticosteroid Related 

AGA X 
CMS-1590-P 447 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

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 

N/A/ 

272 

 Clinical 

Process/ 

Effectivenes

s 

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 

AGA X 

N/A/ 

273 

 Clinical 

Process/ 

Effectivenes

s 

Inflammatory Bowel 

Disease (IBD): 

Preventive Care: 

Pneumococcal 

Immunization: 

Percentage of patients 

aged 18 years and older 

with a diagnosis of 

AGA X 
CMS-1590-P 448 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

inflammatory bowel 

disease that had 

pneumococcal vaccination 

administered or previously 

received 

N/A/ 

274 

 Clinical 

Process/ 

Effectivenes

s 

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 X 

N/A/ 

275 

 Clinical 

Process/ 

Effectivenes

s 

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 who had Hepatitis 

B Virus (HBV) status 

AGA X 
CMS-1590-P 449 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

assessed and results 

interpreted within one 

year prior to receiving a 

first course of anti-TNF 

(tumor necrosis factor) 

therapy 

N/A/ 

276 

 Clinical 

Process/ 

Effectivenes

s 

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 symptoms, 

including presence or 

absence of snoring and 

daytime sleepiness 

AMAPCPI/ 

NCQA 

 X 

N/A/ 

277 

 Clinical 

Process/ 

Effectivenes

s 

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 

AMAPCPI/ 

NCQA 

 X 

N/A/ 

278 

 Clinical 

Process/ 

Effectivenes

s 

Sleep Apnea: Positive 

Airway Pressure 

Therapy Prescribed: 

Percentage of patients 

aged 18 years and older 

with a diagnosis of 

AMAPCPI/ 

NCQA 

 X 
CMS-1590-P 450 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

moderate or severe 

obstructive sleep apnea 

who were prescribed 

positive airway pressure 

therapy 

N/A/ 

279 

 Clinical 

Process/ 

Effectivenes

s 

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 

AMAPCPI/ 

NCQA 

 X 

N/A/ 

280 

 Care 

Coordinatio

n 

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 

AMAPCPI  X 

N/A/ 

281 

 Clinical 

Process/ 

Effectivenes

s 

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 

AMAPCPI 

 X HITE

CH 
CMS-1590-P 451 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

reviewed at least once 

within a 12 month period 

N/A/ 

282 

 Clinical 

Process/ 

Effectivenes

s 

Dementia: Functional 

Status Assessment: 

Percentage of patients, 

regardless of age, with a 

diagnosis of dementia for 

whom an assessment of 

patient’s functional status 

is performed and the 

results reviewed at least 

once within a 12 month 

period 

AMAPCPI 

 X 

N/A/ 

283 

 Clinical 

Process/ 

Effectivenes

s 

Dementia: 

Neuropsychiatric 

Symptom Assessment: 

Percentage of patients, 

regardless of age, with a 

diagnosis of dementia and 

for whom an assessment 

of patient’s 

neuropsychiatric 

symptoms is performed 

and results reviewed at 

least once in a 12 month 

period 

AMAPCPI 

 X 

N/A/ 

284 

 Clinical 

Process/ 

Effectivenes

s 

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 

AMAPCPI 

 X 
CMS-1590-P 452 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

neuropsychiatric 

symptoms within a 12 

month period 

N/A/ 

285 

 Clinical 

Process/ 

Effectivenes

s 

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 

AMAPCPI 

 X 

N/A/ 

286 

 Patient 

Safety 

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 

AMAPCPI  X 

N/A/ 

287 

 Clinical 

Process/ 

Effectivenes

s 

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 

driving alternatives within 

a 12 month period 

AMAPCPI  X 

N/A/ 

288 

 Clinical 

Process/ 

Effectivenes

Dementia: Caregiver 

Education and Support: 

Percentage of patients, 

AMAPCPI  X 
CMS-1590-P 453 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

s 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 

N/A/ 

289 

 Clinical 

Process/ 

Effectivenes

s 

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 than 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 X 

N/A/ 

290 

 Clinical 

Process/ 

Effectivenes

Parkinson’s Disease: 

Psychiatric Disorders or 

Disturbances 

AAN X 
CMS-1590-P 454 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

s 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 

N/A/ 

291 

 Clinical 

Process/ 

Effectivenes

s 

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 X 

N/A/ 

292 

 Clinical 

Process/ 

Effectivenes

s 

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 X 

N/A/ 

293 

 Clinical 

Process/ 

Effectivenes

s 

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, 

AAN X 
CMS-1590-P 455 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

occupational, or speech 

therapy) discussed at least 

annually 

N/A/ 

294 

 Clinical 

Process/ 

Effectivenes

s 

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 X 

N/A/ 

295 

 Clinical 

Process/ 

Effectivenes

s 

Hypertension: 

Appropriate Use of 

Aspirin or Other 

Antiplatelet or 

Anticoagulant Therapy: 

Percentage of patients 

aged 15 through 90 years 

old with a diagnosis of 

hypertension who were 

prescribed aspirin or other 

anticoagulant/antiplatelet 

therapy 

ABIM X 

N/A/ 

296 

 Clinical 

Process/ 

Effectivenes

s 

Hypertension: Complete 

Lipid Profile: Percentage 

of patients aged 15 

through 90 years old with 

ABIM X 
CMS-1590-P 456 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

a diagnosis of 

hypertension who 

received a complete lipid 

profile within 24 months 

N/A/ 

297 

 Clinical 

Process/ 

Effectivenes

s 

Hypertension: Urine 

Protein Test: Percentage 

of patients aged 15 

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 

ABIM X 

N/A/ 

298 

 Clinical 

Process/ 

Effectivenes

s 

Hypertension: Annual 

Serum Creatinine Test: 

Percentage of patients 

aged 15 through 90 years 

old with a diagnosis of 

hypertension who had a 

serum creatinine test done 

within 12 months 

ABIM X 

N/A/ 

299 

 Clinical 

Process/ 

Effectivenes

s 

Hypertension: Diabetes 

Mellitus Screening Test: 

Percentage of patients 

aged 15 through 90 years 

old with a diagnosis of 

hypertension who had a 

diabetes screening test 

within 36 months 

ABIM X 

N/A/ 

300 

 Clinical 

Process/ 

Effectivenes

s 

Hypertension: Blood 

Pressure Control: 

Percentage of patients 

aged 15 through 90 years 

old with a diagnosis of 

ABIM X 
CMS-1590-P 457 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

hypertension who had 

most recent blood 

pressure level under 

control (at goal) 

N/A/ 

301 

 Clinical 

Process/ 

Effectivenes

s 

Hypertension: Low 

Density Lipoprotein 

(LDL-C) Control: 

Percentage of patients 

aged 15 through 90 years 

old with a diagnosis of 

hypertension who had 

most recent LDL 

cholesterol level under 

control (at goal) 

ABIM X 

N/A/ 

302 

 Clinical 

Process/ 

Effectivenes

s 

Hypertension: Dietary 

and Physical Activity 

Modifications 

Appropriately 

Prescribed: Percentage of 

patients aged 15 through 

90 years old with a 

diagnosis of hypertension 

who received dietary and 

physical activity 

counseling at least once 

within 12 months 

ABIM X 

N/A/ 

303 

 Clinical 

Process/ 

Effectivenes

s 

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 

AAO X X 
CMS-1590-P 458 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

90 days following the 

cataract surgery, based on 

completing a preoperative and postoperative visual function 

survey 

N/A/ 

304 

 Patient and 

Family 

Engagement 

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 X X 

0004/ 

305 

 Clinical 

Process/ 

Effectivenes

s 

Initiation and 

Engagement of Alcohol 

and Other Drug 

Dependence Treatment: 

(a) Initiation, (b) 

Engagement: Percentage 

of adolescent and adult 

patients with a new 

episode of alcohol or other 

drug (AOD) dependence 

who initiate treatment 

through an inpatient AOD 

admission, outpatient 

visit, intensive outpatient 

encounter or partial 

NCQA X HITE

CH 
CMS-1590-P 459 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

hospitalization within 14 

days of the diagnosis and 

who initiated treatment 

AND who had two or 

more additional services 

with an AOD diagnosis 

within 30 days of the 

initial visit 

0012/ 

306 

 Population/

Public 

Health 

Prenatal Care: 

Screening for Human 

Immunodeficiency Virus 

(HIV): Percentage of 

patients, regardless of age, 

who gave birth during a 

12-month period who 

were screened for HIV 

infection during the first 

or second prenatal visit 

AMAPCPI 

 X 

0014/ 

307 

 Patient 

Safety 

Prenatal Care: Anti-D 

Immune Globulin: 

Percentage of D (Rh) 

negative, unsensitized 

patients, regardless of age, 

who gave birth during a 

12-month period who 

received anti-D immune 

globulin at 26-30 weeks 

gestation 

AMAPCPI 

 X 

0027/ 

308 

 Population/

Public 

Health 

Smoking and Tobacco 

Use Cessation, Medical 

Assistance: a. Advising 

Smokers and Tobacco 

Users to Quit, b. 

Discussing Smoking and 

Tobacco Use Cessation 

Medications, c. 

NCQA X 
CMS-1590-P 460 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

Discussing Smoking and 

Tobacco Use Cessation 

Strategies: Percentage of 

patients aged 18 years and 

older who were current 

smokers or tobacco users, 

who were seen by a 

practitioner during the 

measurement year and 

who received advice to 

quit smoking or tobacco 

use or whose practitioner 

recommended or 

discussed smoking or 

tobacco use cessation 

medications, methods or 

strategies 

0032/ 

309 

 Clinical 

Process/ 

Effectivenes

s 

Cervical Cancer 

Screening: Percentage of 

women aged 21 through 

63 years who received one 

or more Pap tests to 

screen for cervical cancer 

NCQA X HITE

CH 

0033/ 

310 

 Population/

Public 

Health 

Chlamydia Screening for 

Women: Percentage of 

women aged 15 through 

24 years who were 

identified as sexually 

active and who had at 

least one test for 

chlamydia during the 

measurement year 

NCQA X HITE

CH 

0036/ 

311 

 Clinical 

Process/ 

Effectivenes

s 

Use of Appropriate 

Medications for Asthma: 

Percentage of patients 

aged 5 through 50 years of 

NCQA X HITE

CH 
CMS-1590-P 461 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

age who were identified as 

having persistent asthma 

and were appropriately 

prescribed medication 

during the measurement 

year 

0052/ 

312 

 Efficient 

Use of 

Healthcare 

Resources 

Low Back Pain: Use of 

Imaging Studies: 

Percentage of patients 

with a primary diagnosis 

of low back pain who did 

not have an imaging study 

(plain X-ray, MRI, CT 

scan) within 28 days of 

diagnosis 

NCQA X HITE

CH 

0575/ 

313 

 Clinical 

Process/ 

Effectivenes

s 

Diabetes Mellitus: 

Hemoglobin A1c Control 

(<8%): The percentage of 

patients 18 through 75 

years of age with a 

diagnosis of diabetes (type 

1 or type 2) who had 

HbA1c < 8% 

NCQA X 

N/A/ 

316 

 Clinical 

Process/ 

Effectivenes

s 

Preventive Care and 

Screening: Cholesterol – 

Fasting Low Density 

Lipoprotein (LDL) Test 

Performed AND RiskStratified Fasting LDL: 

Percentage of patients 

aged 20 through 79 years 

whose risk factors* have 

been assessed and a 

fasting LDL test has been 

performed 

*There are three criteria 

CMS/ 

QIP 

 X HITE

CH 

Millio

n 

Hearts 
CMS-1590-P 462 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

for this measure based on 

the patient’s risk category.

1. Highest Level of Risk: 

Coronary Heart Disease 

(CHD) or CHD Risk 

Equivalent 

2. Moderate Level of 

Risk: Multiple (2+) Risk 

Factors 

3. Lowest Level of Risk: 0 

or 1 Risk Factor 

N/A/ 

317 

 Population/

Public 

Health 

Preventive Care and 

Screening: Screening for 

High Blood Pressure: 

Percentage of patients 

aged 18 and older who are 

screened for high blood 

pressure 

CMS/ 

QIP 

X X X X X HITE

CH 

ACO 

Millio

n 

Hearts 

0101/ 

318 

 Patient 

Safety 

Falls: Screening for 

Future Fall Risk: 

Percentage of patients 

aged 65 years and older 

who were screened for 

future fall risk at least 

once within 12 months 

AMAPCPI/ 

NCQA 

 X HITE

CH 

ACO 

TBD/ 

TBD 

X Clinical 

Process/ 

Effectivenes

s 

Stroke and Stroke 

Rehabilitation: Tissue 

Plasminogen Activator 

(t-PA) Considered 

(Paired Measure): 

Percentage of patients 

aged 18 years and older 

with a diagnosis of 

ischemic stroke who 

arrive at the hospital 

within 4.5 hours of time 

AMAPCPI X X 
CMS-1590-P 463 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

last known well who were 

considered for t-PA 

administration

TBD/ 

TBD 

X Clinical 

Process/ 

Effectivenes

s 

Stroke and Stroke 

Rehabilitation: Tissue 

Plasminogen Activator 

(t-PA) Administered 

Initiated (Paired 

Measure): Percentage of 

all patients aged 18 years 

and older with a diagnosis 

of ischemic stroke who 

present within two hours 

of time last known well 

and who are eligible for tPA, for whom t-PA was 

initiated within three 

hours of time last known 

well

AMAPCPI 

X X 

0729/ 

TBD 

X Clinical 

Process/ 

Effectivenes

s 

Diabetes Composite: 

Optimal Diabetes Care: 

Patients ages 18 through 

75 with a diagnosis of 

diabetes, who meet all the 

numerator targets of this 

composite measure: A1c < 

8.0%, LDL < 100 mg/dL, 

blood pressure < 140/90 

mmHg, tobacco non-user 

and for patients with a 

diagnosis of ischemic 

vascular disease daily 

aspirin use unless 

contraindicated

MNCM X ACO 

0658/ 

TBD 

X Care 

Coordinatio

Endoscopy and Polyp 

Surveillance: 

AMAPCPI 

X X 
CMS-1590-P 464 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

n Appropriate Follow-Up 

Interval for Normal 

Colonoscopy in Average 

Risk Patients: Percentage 

of patients aged 50 years 

and older receiving a 

screening colonoscopy 

without biopsy or 

polypectomy who had a 

recommended follow-up 

interval of at least 10 

years for repeat 

colonoscopy documented 

in their colonoscopy 

report

0493/ 

TBD 

X Care 

Coordinatio

n 

Participation by a 

Physician or Other 

Clinician in a Systematic 

Clinical Database 

Registry that Includes 

Consensus Endorsed 

Quality: Participation in a 

systematic qualified 

clinical database registry 

involves: 

a. Physician or other 

clinician submits 

standardized data 

elements to registry 

b. Data elements are 

applicable to consensus 

endorsed quality measures

c. Registry measures shall 

include at least two (2) 

representative NQF 

consensus endorsed 

CMS/ 

QIP 

X X 
CMS-1590-P 465 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

measures for registry's 

clinical topic(s) and report 

on all patients eligible for 

the selected measures. 

d. Registry provides 

calculated measures 

results, benchmarking, 

and quality improvement 

information to individual 

physicians and clinicians. 

e. Registry must receive 

data from more than 5 

separate practices and 

may not be located 

(warehoused) at an 

individual group’s 

practice. Participation in a 

national or state-wide 

registry is encouraged for 

this measure. 

f. Registry may provide 

feedback directly to the 

provider’s local registry if 

one exists

0670/ 

TBD 

X Efficient 

Use of 

Healthcare 

Resources 

Cardiac Stress Imaging 

Not Meeting 

Appropriate Use 

Criteria: Preoperative 

Evaluative in Low-Risk 

Surgery Patients: 

Percentage of stress 

single-photon emission 

computed tomography 

(SPECT) myocardial 

perfusion imaging (MPI), 

stress echo, cardiac 

ACC X 
CMS-1590-P 466 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

computed tomography 

angiography (CCTA), or 

cardiovascular magnetic 

resonance (CMR) 

performed in low risk 

surgery patients for 

preoperative evaluation 

0671/ 

TBD 

X Efficient 

Use of 

Healthcare 

Resources 

Cardiac Stress Imaging 

Not Meeting 

Appropriate Use 

Criteria: Routine 

Testing After 

Percutaneous Coronary 

Intervention (PCI): 

Percentage of all stress 

single-photon emission 

computed tomography 

(SPECT) myocardial 

perfusion imaging (MPI) 

and stress echo performed 

routinely after 

percutaneous cardiology 

intervention (PCI), with 

reference to timing of test 

after PCI and symptom 

status

ACC X 

0672/ 

TBD 

X Efficient 

Use of 

Healthcare 

Resources 

Cardiac Stress Imaging 

Not Meeting 

Appropriate Use 

Criteria: Testing in 

Asyptomatic, Low-Risk 

Patients: Percentage of 

all stress single-photon 

emission computed 

tomography (SPECT) 

myocardial perfusion 

ACC X 
CMS-1590-P 467 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

imaging (MPI), stress 

echo, cardiac computed 

tomography angiography 

(CCTA), and 

cardiovascular magnetic 

resonance (CMR) 

performed in 

asymptomatic, low 

coronary heart disease 

(CHD) risk patients for 

intial detection and risk 

assessment

TBD/ 

TBD 

X Clinical 

Process/ 

Effectivenes

s 

Adult Major Depressive 

Disorder: Coordination 

of Care of Patients with 

Co-Morbid Conditions - 

Timely Follow-Up:

Percentage of medical 

records of patients aged 

18 years and older with a 

diagnosis of MDD and a 

diagnosed co-morbid 

condition being treated by 

another physician with 

communication to the 

other physician treating 

the co-morbid condition 

AMAPCPI  X 

TBD/ 

TBD 

X Care 

Coordinatio

n 

Coordination of Care of 

Patients with Co-Morbid 

Conditions - Timely 

Follow-Up (Paired 

Measure): Percentage of 

medical records of 

patients aged 18 years and 

older with a diagnosis of 

major depressive disorder 

AMAPCPI 

 X 
CMS-1590-P 468 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

(MDD) and a diagnosed 

co-morbid condition with 

communication to another 

physician treating the comorbid condition who 

have a response from the 

other physician within 45 

days of original 

communication OR who 

have a follow-up attempt 

within 60 days of original 

communication by the 

physician treating MDD 

to elicit a response from 

the other physician 

1525/ 

TBD 

X Patient 

Safety 

Atrial Fibrillation and 

Atrial Flutter: Chronic 

Anticoagulation 

Therapy: Percentage of 

patients aged 18 and older 

with nonvalvular AF or 

atrial flutter at high risk 

for thromboembolism, 

according to CHADS2 

risk stratification, who 

were presecribed warfarin 

or another oral 

anticoagulant drug that is 

FDA approved for the 

prevention of 

thromboembolism during 

the 12-month reporting 

period

AMA X X HITE

CH 

TBD/ 

TBD 

X Clinical 

Process/ 

Effectivenes

Pediatric End-Stage 

Renal Disease Measure 

(AMA/ASPN): Pediatric 

AMA/AS

PN 

X X 
CMS-1590-P 469 

Reporting 

Mechanism 

NQF/ PQRS New Measure 

National 

Quality 

Strategy 

Domain 

Measure Title and 

Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-S

electe

d GPRO

(web interface)

*

Measures Groups 

Other Quality Reporting Programs 

s Kidney Disease: 

Adequacy of Volume 

Management: Percentage 

of calendar months within 

a 12-month period during 

which patients aged 17 

years and younger with a 

diagnosis of end-stage 

renal disease (ESRD) 

undergoing maintenance 

hemodialysis in an 

outpatient dialysis facility 

have an assessment of the 

adequacy of volume 

management from a 

nephrologist 

1667/ 

TBD 

X Clinical 

Process/ 

Effectivenes

s 

Pediatric Kidney 

Disease: ESRD Patients 

Receiving Dialysis: 

Hemoglobin Level 

<10g/dL: Percentage of 

calendar months within a 

12-month period during 

which patients aged 17 

years and younger with a 

diagnosis of ESRD 

receiving hemodialysis or 

peritoneal dialysis have a 

Hemoglobin level <10 

g/dL

AMA X X 

*Measures that can be reported using the GPRO web interface. 

†

These measures can only be reported by participants using the GPRO. They are not available for reporting for 

individual Eligible Professionals using this reporting method. 

¥ Titles and descriptions in this table are aligned with proposed 2013 PQRS Electronic Health Records (EHR) 

measure titles, and may differ from existing measures in other programs. Please reference the National Quality 

Forum (NQF) and PQRS numbers for clarification. 
CMS-1590-P 470 

Beginning with reporting periods occurring in 2014, we are proposing the following 45 

individual quality measures specified in Table 33 available for reporting under the PQRS: 

TABLE 33: Proposed PQRS Individual Quality Measures Available for Reporting via 

Claims, Registry, EHR and/or the GPRO Web-Interface for 2014 and Beyond That Were 

NOT Available for Reporting under the 2012 PQRS 

Reporting 

Mechanism 

NQF/ PQRS 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward 

PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-Selected GPRO* (web interface)* Measures Groups 

Other Quality Reporting Programs 

N/A/ 

TBD 

Clinical 

Process/ 

Effectivene

ss 

Preventive Cardiology Composite: 

• Blood Pressure at Goal: Percentage of 

patients in the sample whose most 

recent blood pressure reading was at 

goal

• Low Density Lipids (LDL) 

Cholesterol at Goal: Percentage of 

patients in the sample whose LDL 

cholesterol is considered to be at goal, 

based upon their coronary heart disease 

(CHD) risk factors

• Timing of Lipid Testing Complies 

with Guidelines: Percentage of patients 

in the sample whose timing of lipid 

testing complies with guidelines (lipid 

testing performed in the preceding 12-

month period (with a three-month grace 

period) for patients with known 

coronary heart disease (CHD) or CHD 

risk equivalent (prior myocardial 

infarction (MI), other clinical CHD, 

symptomatic carotid artery disease, 

peripheral artery disease, abdominal 

aortic aneurysm, diabetes mellitus); or 

in the preceding 24-month period (with 

a three-month grace period) for patients 

with > 2 risk factors for CHD (smoking, 

hypertension, low high density lipid 

(HDL), men > 45 years, women > 55 

years, family history of premature 

CHD; HDL > 60 mg/dL acts as a 

negative risk factor); or in the preceding 

60-month period (with a three-month 

grace period) for patients with < 1 risk 

ABIM X 
CMS-1590-P 471 

Reporting 

Mechanism 

NQF/ PQRS 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-Selected GPRO* (web interface)* Measures Groups Other Quality Reporting Programs 

factor for CHD)

• Diabetes Documentation or Screen 

Test: Percentage of patients in the 

sample who had a screening test for 

type 2 diabetes or had a diagnosis of 

diabetes

• Correct Determination of Ten-Year 

Risk for Coronary Death or 

Myocardial Infarction (MI): Number 

of patients in the sample whose ten-year 

risk of coronary death or MI is correctly 

assessed and documented

• Counseling for Diet and Physical 

Activity: Percentage of patients in the 

sample who received dietary and 

physical activity counseling

• Appropriate Use of Aspirin or Other 

Antiplatelet/Anticoagulant Therapy: 

Percentage of patients in the sample 

who are: 1) taking aspirin or other 

anticoagulant/antiplatelet therapy, or 2) 

under age 30, or 3) age 30 or older and 

who are documented to be at low risk. 

Low-risk patients include those who are 

documented with no prior coronary 

heart disease (CHD) or CHD risk 

equivalent (prior myocardial infarction 

(MI), other clinical CHD, symptomatic 

carotid artery disease, peripheral artery 

disease, abdominal aortic aneurysm, 

diabetes mellitus) and whose ten-year 

risk of developing CHD is < 10%

• Smoking Status and Cessation 

Support: Percentage of patients in the 

sample whose current smoking status is 

documented in the chart, and if they 

were smokers, were documented to 

have received smoking cessation 

counseling during the reporting period

N/A/ 

TBD 

Care 

Coordinati

on 

Total Knee Replacement: Coordination of 

Post Discharge Care: Percentage of patients 

undergoing total knee replacement who 

received written instructions for post 

AAHKS

/AMAPCPI 

 

X 
CMS-1590-P 472 

Reporting 

Mechanism 

NQF/ PQRS 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-Selected GPRO* (web interface)* Measures Groups Other Quality Reporting Programs 

discharge care including all the following: 

post discharge physical therapy, home health 

care, post discharge deep vein thrombosis 

(DVT) prophylaxis and follow-up physician 

visits

N/A/ 

TBD 

Patient 

Safety 

Total Knee Replacement: Venous 

Thromboembolic and Cardiovascular 

Risk Evaluation: Percentage of patients 

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 (DVT), pulmonary embolism 

(PE), myocardial infarction (MI), arrhythmia 

and stroke

AAHKS

/AMAPCPI 

 

X 

N/A/ 

TBD 

Patient 

Safety 

Total Knee Replacement: Preoperative 

Antibiotic Infusion with Proximal 

Tourniquet: Percentage of patients 

undergoing a total knee replacement who had 

the prophylactic antibiotic completely 

infused prior to the inflation of the proximal 

tourniquet

AAHKS

/AMAPCPI) 

 

X 

N/A/ 

TBD 

Patient 

Safety 

Total Knee Replacement: Identification of 

Implanted Prosthesis in Operative Report: 

Percentage of patients undergoing total knee 

replacement whose operative report identifies 

the prosthetic implant specifications 

including the prosthetic implant 

manufacturer, the brand name of prosthetic 

implant and the size of prosthetic implant

AAHKS

/AMAPCPI 

 

X 

TBD/ 

TBD 

Care 

Coordinati

on 

Radiation Dose Optimization: Utilization 

of a Standardized Nomenclature for 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 (e.g., RadLex®) 

and the standardized nomenclature is used in 

institutions computer systems 

AMAPCPI  

X 

TBD/ 

TBD 

Patient 

Safety 

Radiation Dose Optimization: Cumulative 

Count of Potential High Dose Radiation 

Imaging Studies: Computed Tomography 

AMAPCPI  

X 
CMS-1590-P 473 

Reporting 

Mechanism 

NQF/ PQRS 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-Selected GPRO* (web interface)* Measures Groups Other Quality Reporting Programs 

(CT) Scans and Cardiac Nuclear Medicine 

Scans: Percentage of CT and cardiac nuclear 

medicine (myocardial perfusion) imaging 

reports for all patients, regardless of age, that 

document a count of known previous CT 

studies (any type of CT) and cardiac nuclear 

medicine (myocardial perfusion studies) 

studies that the patient has received in the 12-

month period prior to the current study

TBD/ 

TBD 

Patient 

Safety 

Radiation Dose Optimization: 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 

AMAPCPI  

X 

TBD/ 

TBD 

Care 

Coordinati

on 

Radiation Dose Optimization: Images 

Available for Patient Follow-up and 

Comparison Purposes: Percentage of final 

reports for imaging studies performed for all 

patients, regardless of age, which document 

that Digital Imaging and Communications in 

Medicine (DICOM) format image data are 

available reciprocally to non-affiliated 

external entities on a secure, media free, 

searchable basis with patient authorization 

for at least a 12-month period after the study 

AMAPCPI  

X 

TBD/ 

TBD 

Care 

Coordinati

on 

Radiation Dose Optimization: Search for 

Prior Imaging Studies Through a Secure, 

Authorized, Media-Free, Shared Archive:

Percentage of final reports of imaging 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 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 

AMAPCPI  

X 

N/A/ 

TBD 

Clinical 

Process/ 

Osteoporosis Composite: 

• Status of Participation in WeightABIM X 
CMS-1590-P 474 

Reporting 

Mechanism 

NQF/ PQRS 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-Selected GPRO* (web interface)* Measures Groups Other Quality Reporting Programs 

Effectivene

ss 

Bearing Exercise and Weight-bearing 

Exercise Advice: Percentage of 

patients aged 18 and older with a 

diagnosis of osteoporosis, osteopenia, 

or prior low impact fracture; women 

age 65 and older; or men age 70 and 

older whose status regarding 

participation in weight-bearing exercise 

was documented and for those not 

participating regularly who received 

advice within 12 months to participate 

in weight-bearing exercise

• Current Level of Alcohol Use and 

Advice on Potentially Hazardous 

Drinking Prevention: Percentage of 

patients aged 18 and older with a 

diagnosis of osteoporosis, osteopenia, 

or prior low impact fracture; women 

age 65 and older; or men age 70 and 

older whose current level of alcohol use 

was documented and for those engaging 

in potentially hazardous drinking who 

received counseling within 12 months

• Screen for Falls Risk Evaluation and 

Complete Falls Risk Assessment and 

Plan of Care: Percentage of patients 

aged 18 and older with a diagnosis of 

osteoporosis, osteopenia, or prior low 

impact fracture; women age 65 and 

older; or men age 70 and older who had 

a screen for falls risk evaluation within 

the past 12 months and for those 

reported as having a history of two or 

more falls, or fall-related injury who 

had a complete risk assessment for falls 

and a falls plan of care within the past 

12 months

• Dual-Emission X-ray Absorptiometry 

(DXA) Scan: Percentage of patients 

aged 18 and older with a diagnosis of 

osteoporosis, osteopenia, or prior low 

impact fracture; women age 65 and 

older; or men age 70 and older who had 
CMS-1590-P 475 

Reporting 

Mechanism 

NQF/ PQRS 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-Selected GPRO* (web interface)* Measures Groups Other Quality Reporting Programs 

a DXA scan and result documented

• Calcium Intake Assessment and 

Counseling: Percentage of patients

aged 18 and older with a diagnosis of 

osteoporosis, osteopenia, or prior low 

impact fracture; women age 65 and 

older; or men age 70 and older who had 

calcium intake assessment and 

counseling at least once within 12 

months

• Vitamin D Intake Assessment and 

Counseling: Percentage of patients

aged 18 and older with a diagnosis of 

osteoporosis, osteopenia, or prior low 

impact fracture; women age 65 and 

older; or men age 70 and older who had 

vitamin D intake assessment and 

counseling at least once within 12

months

• Pharmacologic Therapy: Percentage 

of patients aged 18 and older with a 

diagnosis of osteoporosis, osteopenia, 

or prior low impact fracture; women 

age 65 and older; or men age 70 and 

older who were prescribed 

pharmacologic therapy approved by the 

Food and Drug Administration

N/A/ 

TBD 

Clinical 

Process/ 

Effectivene

ss 

Osteoporosis: Status of Participation in 

Weight-Bearing Exercise and Weightbearing Exercise Advice: Percentage of 

patients aged 18 and older with a diagnosis 

of osteoporosis, osteopenia, or prior low 

impact fracture; women age 65 and older; or 

men age 70 and older whose status regarding 

participation in weight-bearing exercise was 

documented and for those not participating 

regularly who received advice within 12 

months to participate in weight-bearing 

exercise

ABIM X 

N/A/ 

TBD 

Clinical 

Process/ 

Effectivene

ss 

Osteoporosis: Current Level of Alcohol 

Use and Advice on Potentially Hazardous 

Drinking Prevention: Percentage of patients

aged 18 and older with a diagnosis of 

ABIM X 
CMS-1590-P 476 

Reporting 

Mechanism 

NQF/ PQRS 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-Selected GPRO* (web interface)* Measures Groups Other Quality Reporting Programs 

osteoporosis, osteopenia, or prior low impact 

fracture; women age 65 and older; or men 

age 70 and older whose current level of 

alcohol use was documented and for those 

engaging in potentially hazardous drinking 

who received counseling within 12 months

N/A/ 

TBD 

Patient 

Safety 

Osteoporosis: Screen for Falls Risk 

Evaluation and Complete Falls Risk 

Assessment and Plan of Care: Percentage 

of patients aged 18 and older with a 

diagnosis of osteoporosis, osteopenia, or 

prior low impact fracture; women age 65 and 

older; or men age 70 and older who had a 

screen for falls risk evaluation within the past 

12 months and for those reported as having a 

history of two or more falls, or fall-related 

injury who had a complete risk assessment 

for falls and a falls plan of care within the 

past 12 months 

ABIM X

 

N/A/ 

TBD 

Care 

Coordinati

on 

Osteoporosis: Dual-Emission X-ray 

Absorptiometry (DXA) Scan: Percentage of 

patients aged 18 and older with a diagnosis 

of osteoporosis, osteopenia, or prior low 

impact fracture; women age 65 and older; or 

men age 70 and older who had a DXA scan 

and result documented

ABIM X 

N/A/ 

TBD 

Clinical 

Process/ 

Effectivene

ss 

Osteoporosis: Calcium Intake Assessment 

and Counseling: Percentage of patients aged 

18 and older with a diagnosis of 

osteoporosis, osteopenia, or prior low impact 

fracture; women age 65 and older; or men 

age 70 and older who had calcium intake 

assessment and counseling at least once 

within 12 months

ABIM X 

N/A/ 

TBD 

Clinical 

Process/ 

Effectivene

ss 

Osteoporosis: Vitamin D Intake 

Assessment and Counseling: Percentage of 

patients aged 18 and older with a diagnosis 

of osteoporosis, osteopenia, or prior low 

impact fracture; women age 65 and older; or 

men age 70 and older who had vitamin D 

intake assessment and counseling at least 

once within 12 months

ABIM X 

N/A/ Clinical Osteoporosis: Pharmacologic Therapy: ABIM X 
CMS-1590-P 477 

Reporting 

Mechanism 

NQF/ PQRS 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-Selected GPRO* (web interface)* Measures Groups Other Quality Reporting Programs 

TBD Process/ 

Effectivene

ss 

Percentage of patients aged 18 and older with 

a diagnosis of osteoporosis, osteopenia, or 

prior low impact fracture; women age 65 and 

older; or men age 70 and older who were 

prescribed pharmacologic therapy approved 

by the Food and Drug Administration

0060/ 

TBD 

Clinical 

Process/ 

Effectivene

ss 

Hemoglobin A1c Test for Pediatric 

Patients: Percentage of pediatric patients 

with diabetes with a HbA1c test during the 

measurement period 

NCQA X HITECH 

0108/ 

TBD 

Clinical 

Process/ 

Effectivene

ss 

ADHD: Follow-Up Care for Children 

Prescribed Attention-Deficit/Hyperactivity 

Disorder (ADHD) Medication: The 

percentage of children 6 to 12 years of age 

and newly prescribed attentiondeficit/hyperactivity disorder (ADHA) 

medication who had at least three follow-up 

care visits within a 10-month period, one of 

which was within 30 days of when the first 

ADHD medication was dispensed. Two rates 

are reported. 

A. Percentage of children with a prescription 

dispensed for ADHD medication and who 

had one follow-up visit with a practitioner 

with prescribing authority during the 30-Day 

Initiation Phase 

B. Percentage of children with a prescription 

dispensed for ADHD medication who 

remained on the medication for at least 210 

days and who, in addition to the visit in the 

Initiation Phase, had at least two additional 

follow-up visits with a practitioner within 

270 days (9 months) after the Initiation Phase 

ended 

NCQA X HITECH 

0110/ 

TBD 

Clinical 

Process/ 

Effectivene

ss 

Bipolar Disorder and Major Depression: 

Appraisal for alcohol or chemical 

substance use: Percentage of patients with 

depression or bipolar disorder with evidence 

of an initial assessment that includes an 

appraisal for alcohol or chemical substance 

use 

CQAIM

H 

 X HITECH 

0403/ 

TBD 

Efficient 

Use of 

HIV/AIDS: Medical Visits: Percentage of 

patients, regardless of age, with a diagnosis 

AMA/N

CQA 

 X 

HITECH 
CMS-1590-P 478 

Reporting 

Mechanism 

NQF/ PQRS 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-Selected GPRO* (web interface)* Measures Groups Other Quality Reporting Programs 

Healthcare 

Resources 

of HIV/AIDS with at least two medical 

visits during the measurement year with a 

minimum of 60 days between each visit

0608/ 

TBD 

Clinical 

Process/ 

Effectivene

ss 

Pregnant women that had HBsAg testing: 

This measure identifies pregnant women who 

had a HBsAg (hepatitis B) test during their 

pregnancy 

Ingenix X HITECH 

0710/

TBD 

Clinical 

Process/ 

Effectivene

ss 

Depression Remission at Twelve Months: 

Adult patients age 18 and older with major 

depression or dysthymia and an initial PHQ9 score > 9 who demonstrate remission at 

twelve months defined as PHQ-9 score less 

than 5. This measure applies to both patients 

with newly diagnosed and existing 

depression whose current PHQ-9 score 

indicates a need for treatment

MNCM X HITECH 

0712/ 

TBD 

Clinical 

Process/ 

Effectivene

ss 

Depression Utilization of the PHQ-9 Tool: 

Adult patients age 18 and older with the 

diagnosis of major depression or dysthymia 

who have a PHQ-9 tool administered at least 

once during a 4 month period in which there 

was a qualifying visit 

MNCM X HITECH 

1401/ 

TBD 

 Population

/Public 

Health 

Maternal depression screening: The 

percentage of children who turned 6 months 

of age during the measurement year, who had 

a face-to-face visit between the clinician and 

the child during child’s first 6 months, and 

who had a maternal depression screening for 

the mother at least once between 0 and 6 

months of life 

NCQA X HITECH 

Not 

yet 

endors

ed/ 

TBD 

Clinical 

Process/Eff

ectiveness 

Hypertension: Improvement in blood 

pressure: Percentage of patients aged 18-85 

years of age with a diagnosis of hypertension 

whose blood pressure improved during the 

measurement period 

CMS X HITECH 

Not 

yet 

endors

ed/ 

TBD 

 Care 

Coordinati

on 

Closing the referral loop: receipt of 

specialist report: Percentage of patients 

with referrals, regardless of age, for which 

the referring provider receives a report from 

the provider to whom the patient was 

referred 

CMS X HITECH 

Not 

yet 

Patient and 

Family 

Functional status assessment for knee 

replacement: Percentage of patients aged 18 

CMS X HITECH 
CMS-1590-P 479 

Reporting 

Mechanism 

NQF/ PQRS 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-Selected GPRO* (web interface)* Measures Groups Other Quality Reporting Programs 

endors

ed/ 

TBD 

Engageme

nt 

years and older with primary total knee 

arthroplasty (TKA) who completed baseline 

and follow-up (patient-reported) functional 

status assessments 

Not 

yet 

endors

ed/ 

TBD 

Patient and 

Family 

Engageme

nt 

Functional status assessment for hip 

replacement: Percentage of patients aged 18 

years and older with primary total hip 

arthroplasty (THA) who completed baseline 

and follow-up (patient-reported) functional 

status assessments 

CMS X HITECH 

Not 

yet 

endors

ed/ 

TBD 

Patient and 

Family 

Engageme

nt 

Functional status assessment for complex 

chronic conditions: Percentage of patients 

aged 65 years and older with heart failure 

who completed initial and follow-up patientreported functional status assessments 

CMS X HITECH 

TBD/

TBD 

Clinical 

Process/ 

Effectivene

ss 

Children who have dental decay or 

cavities: Percentage of children ages 1-17, 

who have had tooth decay or cavities during 

the measurement period

MCHB, 

HRSA 

 X HITECH 

TBD/

TBD 

Clinical 

Process/ 

Effectivene

ss 

Primary Caries Prevention Intervention 

as Offered by Primary Care Providers, 

including Dentists: Percentage of children, 

age 0-20 years, who received a fluoride 

varnish application during the measurement 

period

Universi

ty of 

Minnes

ota 

 X HITECH 

TBD/

TBD 

Patient 

Safety 

ADE Prevention and Monitoring: 

Warfarin Time in Therapeutic Range: 

Average percentage of time in which 

individuals with atrial fibrillation who are on 

chronic anticoagulation have International 

Normalized Ratio (INR) test results within 

the therapeutic range during the 

measurement period 

CMS X HITECH 

*Measures that can be reported using the GPRO web interface. 

¥ Titles and descriptions in this table are aligned with proposed 2014 Health Information Technology for Economic 

and Clinical Health (HITECH) measure titles, and may differ from existing measures in other programs. Please 

reference the National Quality Forum (NQF) and PQRS numbers for clarification. 

We also note that we are not proposing to include the following 9 measures specified in 

Table 34 for 2014. 
CMS-1590-P 480 

TABLE 34: Measures that are Not Proposed to be Included in the PQRS Measure Set for 

2014 and Beyond 

Reporting 

Mechanism 

NQF/ PQRS 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-Selected GPRO (web interface)* Measures Groups Other Quality Reporting Programs 

0388/ 

105 

Patient 

Safety 

Prostate Cancer: Three Dimensional 

(3D) Radiotherapy: Percentage of 

patients, regardless of age, with a 

diagnosis of clinically localized prostate 

cancer receiving external beam 

radiotherapy as a primary therapy to the 

prostate with or without nodal irradiation 

(no metastases; no salvage therapy) who 

receive three-dimensional conformal 

radiotherapy (3D-CRT) or intensity 

modulated radiation therapy (IMRT)

AMAPCPI X X 

AQA 

adopte

d/ 

173 

Population/

Public 

Health 

Preventive Care and Screening: 

Unhealthy Alcohol Use – Screening: 

Percentage of patients aged 18 years and 

older who were screened for unhealthy 

alcohol use using a systematic screening 

method within 24 months 

AMAPCPI X X X X 

0084/ 

200 

Clinical 

Process/ 

Effectivene

ss 

Heart Failure: Warfarin Therapy for 

Patients with Atrial Fibrillation: 

Percentage of all patients aged 18 and 

older with a diagnosis of heart failure and 

paroxysmal or chronic atrial fibrillation 

who were prescribed warfarin therapy 

AMAPCPI/A

CCF/A

HA 

 X 

0013/ 

237 

Clinical 

Process/ 

Effectivene

ss 

Hypertension (HTN): Blood Pressure 

Measurement: Percentage of patient visits 

for patients aged 18 years and older with a 

diagnosis of HTN with blood pressure 

(BP) recorded 

AMAPCPI  X 

0012/ 

306 

Population/

Public 

Health 

Prenatal Care: Screening for Human 

Immunodeficiency Virus (HIV): 

Percentage of patients, regardless of age, 

who gave birth during a 12-month period 

who were screened for HIV infection 

during the first or second prenatal visit 

AMAPCPI  X 

0014/ 

307 

Patient 

Safety 

Prenatal Care: Anti-D Immune 

Globulin: Percentage of D (Rh) negative, 

unsensitized patients, regardless of age, 

who gave birth during a 12-month period 

who received anti-D immune globulin at 

26-30 weeks gestation

AMAPCPI  X 

0027/ Population/ Smoking and Tobacco Use Cessation, NCQA X 
CMS-1590-P 481 

Reporting 

Mechanism 

NQF/ PQRS 

National 

Quality 

Strategy 

Domain Measure Title and Description¥

Measure Steward PQRS Claims PQRS Qualified Registry PQRS Qualified EHR CMS-Selected GPRO (web interface)* Measures Groups Other Quality Reporting Programs 

308 Public 

Health 

Medical Assistance: a. Advising 

Smokers and Tobacco Users to Quit, b. 

Discussing Smoking and Tobacco Use 

Cessation Medications, c. Discussing 

Smoking and Tobacco Use Cessation 

Strategies: Percentage of patients aged 18 

years and older who were current smokers 

or tobacco users, who were seen by a 

practitioner during the measurement year 

and who received advice to quit smoking 

or tobacco use or whose practitioner 

recommended or discussed smoking or 

tobacco use cessation medications, 

methods or strategies 

0326/4

7 

Care 

Coordinati

on 

Advanced Care Plan: Percentage of 

patients aged 65 years and older who have 

an advanced care plan or surrogate 

decision maker documented in the medical 

record or documentation in the medical 

record that an advanced care plan was 

discussed but the patient did not wish or 

was not able to name a surrogate decision 

maker or provide an advanced care plan

AMAPCPI/ 

NCQA 

 X 

0575/ 

313 

Clinical 

Process/ 

Effectivene

ss 

Diabetes Mellitus: Hemoglobin A1c 

Control (<8%): The percentage of 

patients 18 through 75 years of age with a 

diagnosis of diabetes (type 1 or type 2) 

who had HbA1c < 8% 

NCQA X 

*Measures that can be reported using the GPRO web interface. 

¥ Titles and descriptions in this table are aligned with the proposed 2013 EHR Pilot measure titles, and may differ 

from existing measures in other programs. Please reference the National Quality Forum (NQF) and PQRS numbers 

for clarification. 

For the 2012 PQRS, the PQRS aligned the measures the program had available for EHRbased reporting with the EHR measures available for reporting under the EHR Incentive 

Program (76 FR 73364) and CMS proposes to retain those measures for 2013 and beyond. In 

fact, we are proposing to add or remove measures available for EHR-based reporting that align 

with what has been proposed for reporting under the EHR Incentive Program for CY 2014 (77 
CMS-1590-P 482 

FR 13746). We also intend to align the PQRS measure set with other CMS programs such as the 

Value-based Modifier and Medicare Shared Savings Program. 

As indicated in Tables 29 through 34, we are proposing a total of 264 measures in 2013. 

Of these proposed measures, we note that 250 of these measures were measures previously 

established for reporting under the 2012 PQRS. 14 of these proposed measures are newly 

proposed in 2013. In 2013, we are also proposing to retire 14 measures that were previously 

established for reporting under the 2012 PQRS. In 2014, we are proposing 34 additional new 

measures that were not previously established for reporting under the 2012 PQRS and proposing 

to retire 8 measures that were previously established for reporting under the 2012 PQRS. 

For Table 31, which specifies the tables we are not proposing to retain in the PQRS 

measure set for 2013 and beyond, we are not proposing the following measures for the following 

reasons: 

(1) Stroke and Stroke Rehabilitation: Computed Tomography (CT) or Magnetic 

Resonance Imaging (MRI) Reports: We are not proposing that this measure be because the 

measure is no longer endorsed by NQF and therefore does not satisfy the requirement for PQRS 

to provide consensus-based quality measures under section 1848(k)(2)(C)(i) of the Act. 

Although section 1848(k)(2)(C)(ii) of the Act provides an exception to proposing PQRS 

measures endorsed by the NQF, we are not exercising our authority to use this exception. The 

measure was not recommended for reporting by the Measure Application Partnership and we 

agree with the Measure Applications Partnership’s (MAP) assessment. More information on the 

MAP’s assessment can be found in the “MAP Pre-Rulemaking Report: Input on Measures Under 

Consideration by HHS for 2012 Rulemaking” available at 

http://www.qualityforum.org/Setting_Priorities/Partnership/MAP_Final_Reports.aspx.(2) 

Emergency Medicine: Community-Acquired Pneumonia (CAP): Assessment of Oxygen 
CMS-1590-P 483 

Saturation: The measure was not recommended for reporting by the MAP and we agree with the 

MAP’s assessment. More information on the MAP’s assessment can be found in the “MAP PreRulemaking Report: Input on Measures Under Consideration by HHS for 2012 Rulemaking” 

available at 

http://www.qualityforum.org/Setting_Priorities/Partnership/MAP_Final_Reports.aspx.

(3) Emergency Medicine: Community-Acquired Pneumonia (CAP): Assessment of 

Mental Status; Acute Otitis Externa (AOE): Pain Assessment: The measure was not 

recommended for reporting by the MAP and we agree with the MAP’s assessment. More 

information on the MAP’s assessment can be found in the “MAP Pre-Rulemaking Report: Input 

on Measures Under Consideration by HHS for 2012 Rulemaking” available at 

http://www.qualityforum.org/Setting_Priorities/Partnership/MAP_Final_Reports.aspx.

(4) Carotid Endarterectomy: Use of Patch During Conventional Carotid Endarterectom: 

The measure was not recommended for reporting by the MAP and we agree with the MAP’s 

assessment. More information on the MAP’s assessment can be found in the “MAP PreRulemaking Report: Input on Measures Under Consideration by HHS for 2012 Rulemaking” 

available at 

http://www.qualityforum.org/Setting_Priorities/Partnership/MAP_Final_Reports.aspx.

(5) Chronic Wound Care: Use of Compression System in Patients with Venous Ulcers: 

The measure was not recommended for reporting by the MAP and we agree with the MAP’s 

assessment. More information on the MAP’s assessment can be found in the “MAP PreRulemaking Report: Input on Measures Under Consideration by HHS for 2012 Rulemaking” 

available at 

http://www.qualityforum.org/Setting_Priorities/Partnership/MAP_Final_Reports.aspx.

(6) Referral for Otologic Evaluation for Patients with History of Active Drainage from 
CMS-1590-P 484 

the Ear Within the Previous 90 Days: The measure was not recommended for reporting by the 

MAP and we agree with the MAP’s assessment. More information on the MAP’s assessment 

can be found in the “MAP Pre-Rulemaking Report: Input on Measures Under Consideration by 

HHS for 2012 Rulemaking” available at 

http://www.qualityforum.org/Setting_Priorities/Partnership/MAP_Final_Reports.aspx.

(7) Referral for Otologic Evaluation for Patients with a History of Sudden or Rapidly 

Progressive Hearing Loss: The measure was not recommended for reporting by the MAP and we 

agree with the MAP’s assessment. More information on the MAP’s assessment can be found in 

the “MAP Pre-Rulemaking Report: Input on Measures Under Consideration by HHS for 2012 

Rulemaking” available at 

http://www.qualityforum.org/Setting_Priorities/Partnership/MAP_Final_Reports.aspx.. 

(8) Heart Failure: Patient Education; Functional Communication Measure - Motor Speech

(9) Coronary Artery Disease (CAD): Symptom and Activity Assessment: The measure 

was not recommended for reporting by the MAP and we agree with the MAP’s assessment. 

More information on the MAP’s assessment can be found in the “MAP Pre-Rulemaking Report: 

Input on Measures Under Consideration by HHS for 2012 Rulemaking” available at 

http://www.qualityforum.org/Setting_Priorities/Partnership/MAP_Final_Reports.aspx.

(10) Pregnancy Test for Female Abdominal Pain Patients: The measure was not 

recommended for reporting by the MAP and we agree with the MAP’s assessment. More 

information on the MAP’s assessment can be found in the “MAP Pre-Rulemaking Report: Input 

on Measures Under Consideration by HHS for 2012 Rulemaking” available at 

http://www.qualityforum.org/Setting_Priorities/Partnership/MAP_Final_Reports.aspx.

(11) We also decline to propose the measure titled “Health Information Technology 

(HIT): Adoption/Use of Electronic Health Records (EHR)” again for the 2013 PQRS because of 
CMS-1590-P 485 

our desire to align with the EHR Incentive Program. In addition, we believe that, since we 

anticipate that most eligible professionals reporting via EHR will also participate in the EHR 

Incentive Program, we believe it is redundant to have an eligible professional report on whether 

or not s/he has adopted an EHR. 

(12) We are not proposing the measure titled “Hypertension (HTN): Plan of Care” again 

for 2013 because this measure is being retired by its measure owner. 

For the measures we are not proposing to include in PQRS beginning in 2014 in Table 

34, we did not propose the Prostate Cancer: Three Dimensional (3D) Radiotherapy; 

Hypertension (HTN): Blood Pressure Measurement; and Prenatal Care: Anti-D Immune 

Globulin measures (which are described in detail above in Table 34) for 2014 and beyond 

because the measures will be retired by its measure owners. We are proposing to retire the 

measure titled “Preventive Care and Screening: Unhealthy Alcohol Use – Screening” because 

this measure was recommended for removal from reporting by the Measure Applications 

Partnership. We are proposing to retire the measure titled “Heart Failure: Warfarin Therapy for 

Patients with Atrial Fibrillation” because evidence suggests that treatments other than Warfarin 

have proven more effective to treat Heart Failure. Lastly, we did not propose to retain the 

measures titled “Smoking and Tobacco Use Cessation, Medical Assistance: a. Advising Smokers 

and Tobacco Users to Quit, b. Discussing Smoking and Tobacco Use Cessation Medications, c. 

Discussing Smoking and Tobacco Use Cessation Strategies” and “Advanced Care Plan” for 

reporting via the EHR-based reporting mechanisms beginning in 2014 to align with the EHR 

Incentive Program. 

As indicated in Tables 30 and 32, we are proposing a total of 212 measures for available 

for reporting beginning in 2013. Beginning 2014, we are proposing that 210 measures be 

available for reporting under PQRS. As indicated previously, these proposed measures are 
CMS-1590-P 486 

classified under 6 domains. 

(1) Patient safety. We are proposing 21 measures under the patient safety domain 

available for reporting in PQRS beginning in 2013 or 2014. Of these measures, the following 18 

measures are NQF-endorsed, and therefore satisfy the requirement that PQRS provide 

consensus-based measures for reporting under section 1848(k)(2)(C)(i) of the Act. 

● Perioperative Care: Timing of Antibiotic Prophylaxis – Ordering Physician. 

● Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation 

Cephalosporin. 

● Perioperative Care: Discontinuation of Prophylactic Antibiotics (Non-Cardiac). 

● Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in 

ALL Patients) Perioperative Care. 

● Perioperative Care: Discontinuation of Prophylactic Antibiotics (Cardiac Procedures). 

● Medication Reconciliation: Reconciliation After Discharge from an Inpatient Facility. 

● Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central Venous 

Catheter (CVC) Insertion Protocol. 

● Prostate Cancer: Three Dimensional (3D) Radiotherapy. 

● Documentation of Current Medications in the Medical Record. 

● Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central Venous 

Catheter (CVC) Insertion Protocol. 

● Medication Reconciliation: Reconciliation After Discharge from an Inpatient Facility. 

● Perioperative Care: Discontinuation of Prophylactic Antibiotics (Cardiac Procedures). 

● Perioperative Care: Timely Administration of Prophylactic Parenteral Antibiotics. 

● Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in 

ALL Patients). 
CMS-1590-P 487 

● Perioperative Care: Discontinuation of Prophylactic Antibiotics (Non-Cardiac). 

● Cataracts: Complications within 30 Days Following Cataract Surgery Requiring 

Additional Surgical Procedures. 

● Perioperative Temperature Management. 

● Thoracic Surgery: Pulmonary Function Tests Before Major Anatomic Lung Resection 

(Pneumonectomy, Lobectomy, or Formal Segmentectomy) 

The following 3 measures that are classified under the patient safety domain are not 

NQF-endorsed. For these measures, we are exercising our exception authority under section 

1848(k)(2)(C)(ii) of the Act to propose these measures for reporting under PQRS for the 

following reasons: 

● Falls: Risk Assessment. We are proposing to include this measure under our authority 

under section 1848(k)(2)(C)(ii) to adopt a measure endorsed by the AQA alliance. 

● Elder Maltreatment Screen and Follow-Up Plan. We are proposing to include this 

measure under our authority under section 1848(k)(2)(C)(ii) to adopt a measure endorsed by the 

AQA alliance. 

● Image Confirmation of Successful Excision of Image–Localized Breast Lesion. 

(2) Patient and Family Engagement. We are proposing 5 measures available for reporting 

in PQRS under the patient and family engagement domain beginning in 2013 or 2014. Of these 

measures, the following 4 measures are NQF-endorsed, and therefore satisfy the requirement that 

PQRS provide consensus-based measures for reporting under section 1848(k)(2)(C)(i) of the Act. 

● Oncology: Medical and Radiation – Plan of Care for Pain. 

● Oncology: Medical and Radiation – Pain Intensity Quantified. 

● Osteoarthritis (OA): Function and Pain Assessment. 

● Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 
CMS-1590-P 488 

Years and Older.

The following measure that is classified under the patient and family engagement domain 

is not NQF-endorsed: Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery. 

We are exercising our exception authority under section 1848(k)(2)(C)(ii) of the Act to propose 

this measures for reporting under PQRS because this measure fills a measure satisfaction gap in 

the proposed PQRS measure set. 

(3) Care Coordination. We are proposing 38 measures available for reporting in PQRS 

under the care coordination domain beginning in 2013 or 2014. Of these measures, the 

following 26 measures are NQF-endorsed, and therefore satisfy the requirement that PQRS 

provide consensus-based measures for reporting under section 1848(k)(2)(C)(i) of the Act. 

● 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. 

● Advanced Care Plan. 

● Adult Kidney Disease: Hemodialysis Adequacy: Solute. 

● Adult Kidney Disease: Peritoneal Dialysis Adequacy: Solute. 

● Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of. 

● Melanoma: Coordination of Care. 

● Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 

15 percent OR Documentation of a Plan of Care. 

● Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients 

Undergoing Bone Scintigraphy. 

● Endoscopy & Polyp Surveillance: Colonoscopy Interval for Patients with a History of 

Adenomatous Polyps – Avoidance of Inappropriate Use. 

● Functional Communication Measure - Spoken Language Comprehension. 
CMS-1590-P 489 

● Functional Communication Measure – Attention. 

● Functional Communication Measure – Memory. 

● Functional Communication Measure – Reading. 

● Functional Communication Measure - Spoken Language Expression. 

● Functional Communication Measure – Writing. 

● Functional Communication Measure – Swallowing. 

● Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Knee 

Impairments. 

● Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Hip 

Impairments. 

● Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Lower 

Leg, Foot or Ankle Impairments. 

● Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with 

Lumbar Spine Impairments. 

● Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with 

Shoulder Impairments. 

● Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with 

Elbow, Wrist or Hand Impairments. 

● Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Neck, 

Cranium, Mandible, Thoracic Spine, Ribs, or Other General Orthopedic Impairments. 

● Radiology: Reminder System for Mammograms. 

● Biopsy Follow-Up. 

● Endoscopy and Polyp Surveillance: Appropriate Follow-Up Interval for Normal 

Colonoscopy in Average Risk Patients. 
CMS-1590-P 490 

● Participation by a Physician or Other Clinician in a Systematic Clinical Database 

Registry that Includes Consensus Endorsed Quality. 

Although the following 3 measures classified under the care coordination domain are not 

NQF-endorsed, we are exercising our exception authority under section 1848(k)(2)(C)(ii) of the 

Act to propose these measures for reporting in PQRS because these measures have been 

reviewed by the AQA: 

● Functional Outcome Assessment. 

● Rheumatoid Arthritis (RA): Glucocorticoid Management. 

● Falls: Plan of Care. 

The following 8 measures that are classified under the care coordination domain are also 

not NQF-endorsed. We are exercising our exception authority under section 1848(k)(2)(C)(ii) of 

the Act to propose this measures for reporting under PQRS because these measures fills gaps in 

assessing care coordination in the proposed PQRS measure set. 

● Referral for Otologic Evaluation for Patients with Congenital or Traumatic Deformity 

of the Ear. 

● Surveillance after Endovascular Abdominal Aortic Aneurysm Repair (EVAR). 

● Rate of Open Elective Repair of Small or Moderate Abdominal Aortic Aneurysms 

(AAA) without Major Complications (Discharged to Home by Post-Operative Day #7) 

● Rate of Elective Endovascular Aortic Repair (EVAR) of Small or Moderate 

Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by 

Post- Operative Day #2). 

● Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major 

Complications (Discharged to Home Post-Operative Day #2). 

● Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness. 
CMS-1590-P 491 

● CG-CAHPS Clinician/Group Survey. 

● Coordination of Care of Patients with Co-Morbid Conditions - Timely Follow-Up 

(Paired Measure). 

 (4) Clinical Process/Effectiveness. We are proposing 127 measures available for 

reporting under the clinical process/effectiveness domain in PQRS beginning in 2013 or 2014. 

Of these measures, the following 97 measures are NQF-endorsed, and therefore satisfy the 

requirement that PQRS provide consensus-based measures for reporting under section 

1848(k)(2)(C)(i) of the Act. 

● Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus. 

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

● Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus. 

● Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin 

Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD). 

● Coronary Artery Disease (CAD): Antiplatelet Therapy. 

● Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior 

Myocardial Infarction (MI). 

● Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction 

(LVSD). 

● Anti-depressant medication management: (a) Effective Acute Phase Treatment, (b) 

Effective Continuation Phase Treatment. 

● Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation. 

● Age-Related Macular Degeneration (AMD): Dilated Macular Examination. 

● Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and 

Level of Severity of Retinopathy 
CMS-1590-P 492 

● Diabetic Retinopathy: Communication with the Physician Managing On-going 

Diabetes Care. 

● Aspirin at Arrival for Acute Myocardial Infarction (AMI). 

● Stroke and Stroke Rehabilitation: Deep Vein Thrombosis (DVT) Prophylaxis for 

Ischemic Stroke or Intracranial Hemorrhage. 

● Stroke and Stroke Rehabilitation: Discharged on Antithrombotic Therapy. 

● Stroke and Stroke Rehabilitation: Anticoagulant Therapy Prescribed for Atrial 

Fibrillation (AF) at Discharge. 

● Stroke and Stroke Rehabilitation: Screening for Dysphagia. 

● Stroke and Stroke Rehabilitation: Rehabilitation Services Ordered. 

● Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older. 

● Osteoporosis: Management Following Fracture of Hip, Spine or Distal Radius for Men 

and Women Aged 50 Years and Older. 

● Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years and Older. 

● Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in 

Patients with Isolated CABG: Surgery. 

● Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with 

Isolated CABG Surgery. 

● Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in 

Women Aged 65 Years and Older. 

● Urinary Incontinence: Characterization of Urinary Incontinence in Women Aged 65 

Years and Older. 

● Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation. 

● Chronic Obstructive Pulmonary Disease (COPD): Bronchodilator Therapy. 
CMS-1590-P 493 

● Asthma: Pharmacologic Therapy for Persistent Asthma. 

● Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for NonTraumatic Chest Pain. 

● Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for Syncope. 

● Emergency Medicine: Community-Acquired Pneumonia (CAP): Vital Signs. 

● Emergency Medicine: Community-Acquired Pneumonia (CAP): Empiric Antibiotic. 

● Asthma: Assessment of Asthma Control. 

● Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline. 

● Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in 

Patients Receiving Erythropoietin Therapy. 

● Hematology: Multiple Myeloma: Treatment with Bisphosphonates. 

● Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow CytometryBreast 

Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) 

Positive Breast Cancer. 

● Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients. 

● Hepatitis C: Testing for Chronic Hepatitis C – Confirmation of Hepatitis C Viremia. 

● Hepatitis C: Ribonucleic Acid (RNA) Testing Before Initiating Treatment. 

● Hepatitis C: HCV Genotype Testing Prior to Treatment. 

● Hepatitis C: Antiviral Treatment Prescribed. 

● Hepatitis C: HCV Ribonucleic Acid (RNA) Testing at Week 12 of Treatment. 

● Hepatitis C: Counseling Regarding Risk of Alcohol Consumption. 

● Hepatitis C: Counseling Regarding Use of Contraception Prior to Antiviral Therapy. 

● Acute Otitis Externa (AOE): Topical Therapy. 

● Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN 
CMS-1590-P 494 

Category (Regional Lymph Nodes) with Histologic Grade. 

● Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and 

pN Category (Regional Lymph Nodes) with Histologic Grade. 

● Prostate Cancer: Adjuvant Hormonal Therapy for High-Risk Prostate Cancer Patients. 

● Major Depressive Disorder (MDD): Diagnostic Evaluation. 

● Major Depressive Disorder (MDD): Suicide Risk Assessment. 

● Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug (DMARD) 

Therapy. 

● Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and 

Older. 

● Preventive Care and Screening: Screening Mammography . 

● Preventive Care and Screening: Colorectal Cancer Screening. 

● Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or 

Angiotensin Receptor Blocker (ARB) Therapy for Patients with CAD and Diabetes and/or Left 

Ventricular Systolic Dysfunction (LVSD. 

● Diabetes: Urine Screening. 

● Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy . 

● Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of 

Footwear. 

● Melanoma: Continuity of Care – Recall System:. 

● Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement. 

● Osteoarthritis (OA): Assessment for Use of Anti-Inflammatory or Analgesic Over-theCounter (OTC) Medications. 

● HIV/AIDS: CD4+ Cell Count or CD4+ Percentage. 
CMS-1590-P 495 

● HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis. 

● HIV/AIDS: Adolescent and Adult Patients with HIV/AIDS Who Are Prescribed 

Potent Antiretroviral Therapy. 

● HIV/AIDS: HIV RNA Control After Six Months of Potent Antiretroviral Therapy. 

● Diabetes Mellitus: Foot Exam. 

● Coronary Artery Bypass Graft (CABG): Prolonged Intubation. 

● Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate. 

● Coronary Artery Bypass Graft (CABG): Stroke. 

● Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure. 

● Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration. 

● Coronary Artery Bypass Graft (CABG): Antiplatelet Medications at Discharge. 

● Coronary Artery Bypass Graft (CABG): Beta-Blockers Administered at Discharge. 

● Coronary Artery Bypass Graft (CABG): Anti-Lipid Treatment at Discharge. 

● Hemodialysis Vascular Access Decision-Making by Surgeon to Maximize Placement 

of Autogenous Arterial Venous (AV) Fistula. 

● Stroke and Stroke Rehabilitation: Thrombolytic Therapy. 

● Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery. 

● Oncology: Cancer Stage Documented. 

● Radiology: Stenosis Measurement in Carotid Imaging Reports. 

● Coronary Artery Disease (CAD): Lipid Control. 

● Heart Failure: Left Ventricular Ejection Fraction (LVEF) Assessment. 

● Ischemic Vascular Disease (IVD): Blood Pressure Management Control. 

● Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic. 

● HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia and Gonorrhea. 
CMS-1590-P 496 

● HIV/AIDS: Screening for High Risk Sexual Behaviors. 

● HIV/AIDS: Screening for Injection Drug Use. 

● HIV/AIDS: Sexually Transmitted Disease Screening for Syphilis. 

● Heart Failure (HF): Left Ventricular Function (LVF) Testing. 

● Thoracic Surgery: Recording of Performance Status Prior to Lung or Esophageal 

Cancer Resection. 

● Hypertension (HTN): Controlling High Blood Pressure. 

● Ischemic Vascular Disease (IVD): Complete Lipid Panel and Low Density Lipoprotein 

(LDL-C) Control. 

● Cardiac Rehabilitation Patient Referral from an Outpatient Setting. 

● Anticoagulation for Acute Pulmonary Embolus Patients. 

● Ultrasound Determination of Pregnancy Location for Pregnant Patients withRh 

Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure. 

● Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level 

<10g/dL. 

We are proposing 29 measures for inclusion in the PQRS measure set under the clinical 

process domain in 2013/2014 that are not NQF-endorsed. Although the following 11 measures 

classified under the clinical domain are not NQF-endorsed, we are exercising our exception 

authority under section 1848(k)(2)(C)(ii) of the Act to propose these measures for reporting in 

PQRS because these measures have been reviewed by the AQA: 

● Adult Kidney: Disease Laboratory Testing (Lipid Profile). 

● Adult Kidney Disease: Blood Pressure Management. 

● Adult Kidney Disease: Patients On Erythropoiesis-Stimulating Agent (ESA) - 

Hemoglobin Level > 12.0 g/dL. 
CMS-1590-P 497 

● Rheumatoid Arthritis (RA): Tuberculosis Screening. 

● Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity. 

● Rheumatoid Arthritis (RA): Functional Status Assessment. 

● Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis. 

● Chronic Wound Care: Use of Wound Surface Culture Technique in Patients with 

Chronic Skin Ulcers. 

● Chronic Wound Care: Use of Wet to Dry Dressings in Patients with Chronic Skin 

Ulcers. 

● Substance Use Disorders: Counseling Regarding Psychosocial and Pharmacologic 

Treatment Options for Alcohol Dependence. 

● Substance Use Disorders: Screening for Depression Among Patients with Substance 

Abuse or Dependence. 

The following 18 measures that are classified under the care coordination domain are also 

not NQF-endorsed. We are exercising our exception authority under section 1848(k)(2)(C)(ii) of 

the Act to propose this measures for reporting under PQRS because these measures fill gaps in 

measuring clinical process in the proposed PQRS measure set. 

● Asthma: Tobacco Use: Screening - Ambulatory Care Setting. 

● Asthma: Tobacco Use: Intervention - Ambulatory Care Setting. 

● Coronary Artery Disease (CAD): Symptom Management. 

● Hypertension: Blood Pressure Management. 

● Barrett's Esophagus. 

● Radical Prostatectomy Pathology Reporting. 

● Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Receptor 

2 Testing (HER2) for Breast Cancer Patients. 
CMS-1590-P 498 

● Statin Therapy at Discharge after Lower Extremity Bypass (LEB). 

● Preoperative Diagnosis of Breast Cancer. 

● Sentinel Lymph Node Biopsy for Invasive Breast Cancer. 

● Epilepsy: Seizure Type(s) and Current Seizure Frequency(ies). 

● Epilepsy: Documentation of Etiology of Epilepsy or Epilepsy Syndrome. 

● Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy. 

● Cataracts: Improvement in Patient’s Visual Function within 90 Days Following 

Cataract Surgery. 

● Stroke and Stroke Rehabilitation: Tissue Plasminogen Activator (t-PA) Considered 

(Paired Measure). 

● Stroke and Stroke Rehabilitation: Tissue Plasminogen Activator (t-PA) Administered 

Initiated (Paired Measure) . 

● Adult Major Depressive Disorder: Coordination of Care of Patients with Co-Morbid 

Conditions - Timely Follow-Up. 

● Pediatric End-Stage Renal Disease Measure (AMA/ASPN): Pediatric Kidney Disease: 

Adequacy of Volume Management. 

 (5) Population/Public Health. We are proposing 9 measures classified under the 

population/public health available for reporting in PQRS beginning in 2013 or 2014. Of these 

measures, the following 7 measures are NQF-endorsed, and therefore, satisfy the requirement 

that PQRS provide consensus-based measures for reporting under section 1848(k)(2)(C)(i) of the 

Act. 

● Preventive Care and Screening: Influenza Immunization. 

● Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up. 

● Pain Assessment and Follow-Up. 
CMS-1590-P 499 

● Preventive Care and Screening: Screening for Clinical Depression and Follow-Up 

Plan. 

● Hepatitis C: Hepatitis A Vaccination in Patients with HCV. 

● Hepatitis C: Hepatitis B Vaccination in Patients with HCV. 

● Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention. 

Two proposed PQRS measures in the population/public health domain are not NQFendorsed. Although the measure “Preventive Care and Screening: Unhealthy Alcohol Use – 

Screening” classified under the population/public health domain is not NQF-endorsed, we are 

exercising our exception authority under section 1848(k)(2)(C)(ii) of the Act to propose this 

measure for reporting in PQRS because the measure have been reviewed by the AQA. The 

measure “Preventive Care and Screening: Screening for High Blood Pressure” classified under 

the population/public health domain is also not NQF-endorsed. However, we are exercising our 

exception authority under section 1848(k)(2)(C)(ii) of the Act to propose this measure for 

reporting under PQRS because the measures fill gaps in assessing population/public health safety 

in the proposed PQRS measure set. 

(6) Efficiency. We are proposing 9 measures available for reporting in PQRS beginning 

in 2013 or 2014. Of these measures, all measures are NQF-endorsed, and therefore satisfy the 

requirement that PQRS provide consensus-based measures for reporting under section 

1848(k)(2)(C)(i) of the Act. 

● Treatment for Children with Upper Respiratory Infection (URI): Avoidance of 

Inappropriate Use. 

● Appropriate Testing for Children with Pharyngitis. 

● Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low-Risk Prostate 

Cancer Patients. 
CMS-1590-P 500 

● Antibiotic Treatment for Adults with Acute Bronchitis: Avoidance of Inappropriate 

Use. 

● Radiology: Inappropriate Use of “Probably Benign” Assessment Category in 

Mammography Screening. 

● Melanoma: Overutilization of Imaging Studies in Melanoma. 

● Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative 

Evaluative in Low-Risk Surgery Patients. 

● Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After 

Percutaneous Coronary Intervention (PCI). 

● Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in 

Asyptomatic, Low-Risk Patients. 

Please note that the titles of the measures may change slightly from CMS program and/or 

CMS program year based on specifications updates. We intend to continue to work toward 

complete alignment of measure specifications across programs whenever possible. 

(3) Proposed PQRS quality measures Available for Reporting for Group Practices Using the 

GPRO Web-Interface 

 We have previously discussed our measure proposals for group practices using the GPRO 

web-interface. However, in order to emphasize the measures we are proposing for group 

practices using the GPRO web-interface, we have provided a summary of these proposed 

measures in the following Table 32. As indicated in Table 35, we are proposing 18 measures for 

reporting under the PQRS using the GPRO web-interface for 2013 and beyond to align with the 

quality measures available for reporting under the Medicare Shared Savings Program (76 FR 

67890). Please note that the Medicare Shared Savings Program indicates that it established 22 

measures. There is a discrepancy because the Medicare Shared Savings Program lists the 
CMS-1590-P 501 

Diabetes Composite measure as separate measures, whereas we are referring to the Diabetes 

Composite measure as one measure in Table 35. 

TABLE 35: Measures Proposed to be Included in the Group Practice Reporting Option 

(GPRO) Web-Based Interface for 2013 and Beyond¥ 

NQF/ PQRS 

GPRO 

Disease 

Module 

National 

Quality 

Strategy 

Domain Measure and Title Description 

Measure Steward 

Other Quality 

Reporting Programs 

0059/ 

1 

Diabetes 

Mellitus 

Clinical 

Process/ 

Effectivene

ss 

Diabetes: Hemoglobin A1c Poor Control: Percentage 

of patients 18-75 years of age with diabetes (type 1 or 

type 2) who had hemoglobin A1c > 9.0% 

NCQA HITECH 

ACO 

0083/ 

8 

Heart 

Failure 

Clinical 

Process/ 

Effectivene

ss 

Heart Failure (HF): Beta-Blocker Therapy for Left 

Ventricular Systolic Dysfunction (LVSD): Percentage 

of patients aged 18 years and older with a diagnosis of 

heart failure (HF) with a current or prior left ventricular 

ejection fraction (LVEF) < 40% who were prescribed 

beta-blocker therapy either within a 12 month period 

when seen in the outpatient setting OR at each hospital 

discharge 

AMAPCPI/ 

ACCF/A

HA 

HITECH 

ACO 

0097/ 

46 

Care 

Coordinati

on/ 

Patient 

Safety 

Patient 

Safety 

Medication Reconciliation: Percentage of patients aged 

65 years and older discharged from any inpatient facility 

(e.g. hospital, skilled nursing facility, or rehabilitation 

facility) and seen within 60 days following discharge in 

the office by the physician providing on-going care who 

had a reconciliation of the discharge medications with 

the current medication list in the medical record 

documented 

AMAPCPI/ 

NCQA 

HITECH 

ACO 

0041/ 

110 

Preventive 

Care 

Population/

Public 

Health 

Preventive Care and Screening: Influenza 

Immunization: Percentage of patients aged 6 months 

and older seen for a visit between October 1 and March 

31 who received an influenza immunization OR who 

reported previous receipt of an influenza immunization 

AMAPCPI HITECH 

ACO 

0043/ 

111 

Preventive 

Care 

Clinical 

Process/ 

Effectivene

ss 

Pneumonia Vaccination Status for Older Adults: 

Percentage of patients 65 years of age and older who 

have ever received a pneumococcal vaccine 

NCQA HITECH 

ACO 

0031/ 

112 

Preventive 

Care 

Clinical 

Process/ 

Effectivene

ss 

Breast Cancer Screening: Percentage of women 40-69 

years of age who had a mammogram to screen for breast 

cancer 

NCQA HITECH 

ACO 

0034/ 

113 

Preventive 

Care 

Clinical 

Process/ 

Effectivene

ss 

Colorectal Cancer Screening: Percentage of adults 50-

75 years of age who had appropriate screening for 

colorectal cancer 

NCQA HITECH 

ACO 

0066/ 

118 

Coronary 

Artery 

Disease 

Clinical 

Process/ 

Effectivene

Coronary Artery Disease (CAD): Angiotensinconverting Enzyme (ACE) Inhibitor or Angiotensin 

Receptor Blocker (ARB) Therapy -- Diabetes or Left 

AMAPCPI/ 

ACCF/ 

HITECH 

ACO 
CMS-1590-P 502 NQF/ PQRS 

GPRO 

Disease 

Module 

National 

Quality 

Strategy 

Domain Measure and Title Description 

Measure Steward 

Other Quality 

Reporting Programs 

ss 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 diabetes OR a current or 

prior Left Ventricular Ejection Fraction (LVEF) < 40% 

who were prescribed ACE inhibitor or ARB therapy 

AHA 

0421/ 

128 

Preventive 

Care 

Population/

Public 

Health 

Adult Weight Screening and Follow-Up: Percentage 

of patients aged 18 years and older with a calculated 

body mass index (BMI) in the past six months or during 

the current visit documented in the medical record AND 

if the most recent BMI is outside of normal parameters, 

a follow-up plan is documented 

Normal Parameters: Age 65 years and older BMI ≥ 23 

and < 30 

Age 18-64 years BMI ≥ 18.5 and < 25

CMS/ 

QIP 

HITECH 

ACO 

0418/ 

134 

Preventive 

Care 

Population/

Public 

Health 

Screening for Clinical Depression: Percentage of 

patients aged 12 years and older screened for clinical 

depression using an age appropriate standardized tool 

and follow up plan documented 

CMS/ 

QIP 

HITECH 

ACO 

0074/ 

197 

Coronary 

Artery 

Disease 

Clinical 

Process/ 

Effectivene

ss 

Coronary Artery Disease (CAD): Lipid Control: 

Percentage of patients aged 18 years and older with a 

diagnosis of coronary artery disease seen within a 12 

month period who have a LDL-C result <100 mg/dL OR 

patients who have a LDL-C result ≥100 mg/dL and have 

a documented plan of care to achieve LDL-C 

<100mg/dL, including at a minimum the prescription of 

a statin 

AMAPCPI/ 

ACCF/ 

AHA 

HITECH 

ACO 

0068/ 

204 

Ischemic 

Vascular 

Disease 

Clinical 

Process/ 

Effectivene

ss 

Ischemic Vascular Disease (IVD): Use of Aspirin or 

Another Antithrombotic: Percentage of patients 18 

years of age and older who were discharged alive for 

acute myocardial infarction (AMI), coronary artery 

bypass graft (CABG) or percutaneous transluminal 

coronary angioplasty (PTCA) from January 1-November 

1 of the year prior to the measurement year, or who had 

a diagnosis of ischemic vascular disease (IVD) during 

the measurement year and the year prior to the 

measurement year and who had documentation of use of 

aspirin or another antithrombotic during the 

measurement year 

NCQA HITECH 

ACO 

Million 

Hearts 

0028/ 

226 

Preventive 

Care 

Population/

Public 

Health 

Preventive Care and Screening: Tobacco Use: 

Screening and Cessation Intervention: Percentage of 

patients aged 18 years and older who were screened for 

tobacco use one or more times within 24 months AND 

who received cessation counseling intervention if 

identified as a tobacco user 

AMAPCPI HITECH 

ACO 

Million 

Hearts 

0018/ 

236 

Hypertens

ion 

Clinical 

Process/ 

Controlling High Blood Pressure: Percentage of 

patients 18-85 years of age who had a diagnosis of 

NCQA HITECH 

ACO 
CMS-1590-P 503 NQF/ PQRS 

GPRO 

Disease 

Module 

National 

Quality 

Strategy 

Domain Measure and Title Description 

Measure Steward 

Other Quality 

Reporting Programs 

Effectivene

ss 

hypertension and whose blood pressure was adequately 

controlled during the measurement year

Million 

Hearts 

0075/ 

241 

Ischemic 

Vascular 

Disease 

Clinical 

Process/ 

Effectivene

ss 

Ischemic Vascular Disease (IVD): Complete Lipid 

Panel and LDL Control: 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 transluminal 

angioplasty (PTCA) from January 1-November 1 of the 

year prior to the measurement year, or who had a 

diagnosis of ischemic vascular disease (IVD) during the 

measurement year and the year prior to the measurement 

year and who had a complete lipid profile performed 

during the measurement year and whose LDL-C<100 

mg/dL 

NCQA HITECH 

ACO 

Million 

Hearts 

N/A/ 

317 

Preventive 

Care 

Population/

Public 

Health 

Preventive Care and Screening: Screening for High 

Blood Pressure: Percentage of patients aged 18 years 

and older who are screened for high blood pressure 

CMS/ 

QIP 

HITECH 

ACO 

Million 

Hearts 

0101/ 

318 

Care 

Coordinati

on/ 

Patient 

Safety 

Patient 

Safety 

Falls: Screening for Fall Risk: Percentage of patients 

aged 65 years and older who were screened for future 

fall risk (patients are considered at risk for future falls if 

they have had 2 or more falls in the past year or any fall 

with injury in the past year) at least once within 12 

months 

AMAPCPI/ 

NCQA 

HITECH 

ACO 

0729/ 

TBD 

Diabetes 

Mellitus 

Clinical 

Process/ 

Effectivene

ss 

Diabetes Composite: Optimal Diabetes Care: Patients 

ages 18 through 75 with a diagnosis of diabetes, who 

meet all the numerator targets of this composite 

measure: 

• A1c < 8.0%

• LDL < 100 mg/dL

• blood pressure < 140/90 mmHg

• tobacco non-user 

• (for patients with a diagnosis of ischemic 

vascular disease) daily aspirin use unless 

contraindicated

MNCM ACO 

¥ Titles and descriptions in this table are aligned with the proposed 2013 PQRS Electronic Health Records (EHR) 

measure titles, and may differ from existing measures in other programs. Please reference the National Quality 

Forum (NQF) and PQRS numbers for clarification. 

 We note that, due to our desire to align with the measures available for reporting under 

the Medicare Shared Savings Program, we are proposing not to retain the 13 measures specified 

in Table 36 for purposes of reporting via the GPRO-web interface beginning in 2013. 
CMS-1590-P 504 

TABLE 36: Measures Included in the 2012 PQRS Group Practice Reporting Option WebBased Interface that are Not Proposed for Inclusion in the Web-Based Interface Beginning 

in 2013¥ 

NQF/ PQRS 

GPRO 

Disease 

Module 

National 

Quality 

Strategy 

Domain Measure Title and Description 

Measure Steward Other Quality Reporting Programs 

0064/ 

2 

Diabetes 

Mellitus 

Clinical 

Process/ 

Effectivene

ss 

Diabetes Mellitus: Low Density Lipoprotein (LDL-C) 

Control in Diabetes Mellitus: Percentage of patients 

aged 18 through 75 years with diabetes mellitus who had 

most recent LDL-C level in control (less than 100 mg/dL) 

NCQA Million 

Hearts 

0061/ 

3 

Diabetes 

Mellitus 

Clinical 

Process/ 

Effectivene

ss 

Diabetes Mellitus: High Blood Pressure Control in 

Diabetes Mellitus: Percentage of patients aged 18 

through 75 years with diabetes mellitus who had most 

recent blood pressure in control (less than 140/90 mmHg) 

NCQA 

0081/ 

5 

Heart 

Failure 

Clinical 

Process/ 

Effectivene

ss 

Heart Failure: 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 and 

LVSD (LVEF < 40%) who were prescribed ACE 

inhibitor or ARB therapy 

AMAPCPI/ 

ACCF/A

HA 

0067/ 

6 

Coronary 

Artery 

Disease 

Clinical 

Process/ 

Effectivene

ss 

Coronary Artery Disease (CAD): Antiplatelet 

Therapy: Percentage of patients aged 18 years and older 

with a diagnosis of coronary artery disease seen within a 

12 month period who were prescribed aspirin or 

clopidogrel 

AMAPCPI/ 

ACCF/A

HA 

0102/ 

52 

Chronic 

Obstructiv

e 

Pulmonar

y Disease 

Clinical 

Process/ 

Effectivene

ss 

Chronic Obstructive Pulmonary Disease (COPD): 

Bronchodilator Therapy: 

Percentage of patients aged 18 years and older with a 

diagnosis of COPD and who have an FEV1/FVC less 

than 70% and have symptoms who were prescribed an 

inhaled bronchodilator 

AMAPCPI 

0055/ 

117 

Diabetes 

Mellitus 

Clinical 

Process/ 

Effectivene

ss 

Diabetes Mellitus: Dilated Eye Exam in Diabetic 

Patient: Percentage of patients aged 18 through 75 years 

with a diagnosis of diabetes mellitus who had a dilated 

eye exam 

NCQA 

0056/ 

163 

Diabetes 

Mellitus 

Clinical 

Process/ 

Effectivene

ss 

Diabetes Mellitus: Foot Exam: The percentage of 

patients aged 18 through 75 years with diabetes who had 

a foot examination 

NCQA HITECH 

0079/ 

198 

Heart 

Failure 

Clinical 

Process/ 

Effectivene

ss 

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 result (of a recent or prior 

[any time in the past] LVEF assessment) is documented 

within a 12 month period 

AMAPCPI/ 

ACCF/A

HA 

0082/ 

199 

Heart 

Failure 

Clinical 

Process/ 

Effectivene

ss 

Heart Failure: Patient Education: Percentage of 

patients aged 18 years and older with a diagnosis of heart 

failure who were provided with patient education on 

disease management and health behavior changes during 

one or more visit(s) within 12 months 

CMS/ 

QIP 
CMS-1590-P 505 NQF/ PQRS 

GPRO 

Disease 

Module 

National 

Quality 

Strategy 

Domain Measure Title and Description 

Measure Steward Other Quality Reporting Programs 

0079/ 

228 

Heart 

Failure 

Clinical 

Process/ 

Effectivene

ss 

Heart Failure (HF): Left Ventricular Function (LVF) 

Testing: Percentage of patients 18 years and older with 

LVF testing performed during the measurement period 

for patients hospitalized with a principal diagnosis of HF 

during the reporting period 

CMS/ 

QIP 

0575/ 

313 

Diabetes 

Mellitus 

Clinical 

Process/ 

Effectivene

ss 

Diabetes Mellitus: Hemoglobin A1c Control (<8%): 

The percentage of patients 18 through 75 years of age 

with a diagnosis of diabetes (type 1 or type 2) who had 

HbA1c < 8% 

NCQA HITECH 

0729/ 

314 

Diabetes 

Mellitus 

Clinical 

Process/ 

Effectivene

ss 

Diabetes Mellitus: Daily Aspirin Use for Patients with 

Diabetes and Ischemic Vascular Disease Percentage of 

patients aged 18 to 75 years of age with diabetes mellitus 

and ischemic vascular disease with documented daily 

aspirin use during the measurement year unless 

contraindicated 

MNCM 

0729/ 

315 

Diabetes 

Mellitus 

Clinical 

Process/ 

Effectivene

ss 

Diabetes Mellitus: Tobacco Non Use Percentage of 

patients with a diagnosis of diabetes who indicated they 

were tobacco non- users 

MNCM 

¥ Titles and descriptions in this table are aligned with the proposed 2013 PQRS Electronic Health Records (EHR) 

measure titles, and may differ from existing measures in other programs. Please reference the National Quality 

Forum (NQF) and PQRS numbers for clarification 

 In addition to the measures we are proposing in Table 36, we are also proposing to have 

the following measure available for reporting occurring in 2013 and beyond: CG-CAHPS 

Clinician/Group Survey: Getting timely care, appointments and information; How well your 

doctors communicate; Patients rating of doctor; Access to specialists; Health promotion and 

education; Shared decision making; Courteous and helpful office staff; Care coordination; 

Between visit communication; Educating patients about medication adherences; and Stewardship 

of patient resources. We note that this survey measure requires a different form of data 

collection and analysis than the other proposed measures in the PQRS. Therefore, for this 

measure only, CMS intends to administer the survey on behalf of the group practices 

participating in the 2013 PQRS GPRO. In other words, CMS intends to collect the data for this 

measure on group practices’ behalf for CY 2013 reporting periods. 
CMS-1590-P 506 

 (4) Proposed PQRS measures groups Available for Reporting for 2013 and Beyond 

We propose the following 20 measures groups for reporting in the PQRS beginning with 

reporting periods occurring in 2013: Diabetes Mellitus; Chronic Kidney Disease (CKD); 

Preventive Care; Coronary Artery Bypass Graft (CABG); Rheumatoid Arthritis (RA); 

Perioperative Care; Back Pain; Hepatitis C; Heart Failure (HF); Coronary Artery Disease (CAD); 

Ischemic Vascular Disease (IVD); HIV/AIDS; Asthma; Chronic Obstructive Pulmonary Disease 

(COPD); Inflammatory Bowel Disease (IBD); Sleep Apnea; Dementia; Parkinson’s Disease; 

Hypertension; Cardiovascular Prevention; and Cataracts. These 20 proposed measures groups 

were available for reporting under the PQRS in 2012. 

Beginning in 2013, we are proposing the oncology measures groups for reporting under 

the PQRS that provides measures available for reporting related to breast cancer and colon 

cancer. We believe it is important to measure cancer care. 

We propose the following 4 measures groups for inclusion in the PQRS beginning with 

reporting periods occurring in 2014: Osteoporosis; Total Knee Replacement; Radiation Dose; 

and Preventive Cardiology. These measures groups address conditions that the measures groups 

established in 2012 do not address. 

In 2012, the PQRS included a community-acquired pneumonia (CAP) measures group 

among others. We are not proposing to include this measures group again in the PQRS measure 

set for the 2013 PQRS or subsequent years because measures contained within this measures 

group were not recommended for retention by the Measure Applications Partnership. We are 

also proposing, as identified in Table 47, to change the composition of the Coronary Artery 

Disease (CAD) measures group from what was finalized for 2012. Specifically, we are 

proposing to remove PQRS measure #196: Coronary Artery Disease (CAD): Symptom and 

Activity Assessment and replace this measure with PQRS measure #242: Coronary Artery 
CMS-1590-P 507 

Disease (CAD): Symptom Management in the CAD measures group, because the measure #196 

was not recommended for retention by the measure applications partnership. On the hand, 

measure #242 was recommended for retention by the Measure Applications Partnership. 

Descriptions of the measures we are proposing within each proposed measures group are 

provided in Tables 37 through 62. Please note that some of the proposed measures included 

within a proposed PQRS quality measures group may also be available for reporting as an 

individual measure. 

TABLE 37: 2013 and Beyond Proposed Measures – Diabetes Mellitus Measures Group* 

NQF/ 

PQRS Measure Title and Description Measure 

Developer 

0059/ 

1 

Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus: Percentage of 

patients aged 18 through 75 years with diabetes mellitus who had most recent hemoglobin 

A1c greater than 9.0 percent 

NCQA 

0064/ 

2 

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

Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent 

LDL-C level in control (less than 100 mg/dL) 

NCQA 

0061/ 

3 

Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus: Percentage of 

patients aged 18 through 75 years with diabetes mellitus who had most recent blood pressure 

in control (less than 140/90 mmHg) 

NCQA 

0055/ 

117 

Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient: Percentage of patients aged 18 

through 75 years with a diagnosis of diabetes mellitus who had a dialated eye exam 

NCQA 

0062/ 

119 

Diabetes Mellitus: Urine Screening: Percentage of patients aged 18 through 75 years with 

diabetes (type 1 or type 2) who had a nephropathy screening test or evidence of nephropathy 

NCQA 

0056/ 

163 

Diabetes Mellitus: Foot Exam: The percentage of patients aged 18 through 75 years with 

diabetes who had a foot examination 

NCQA 

 *This measures group is reportable through both claims and registry-based reporting. 

TABLE 38: 2013 and Beyond Proposed Measures – Chronic Kidney Disease (CKD) 

Measures Group*

NQF/ 

PQRS Measure Title and Description Measure Developer 

0041/ 

110 

Preventive Care and Screening: Influenza Immunization: Percentage of patients aged 

6 months and older who received an influenza immunization during the flu season 

(October 1 through March 31) 

AMAPCPI 

AQA 

adopted/1

21 

Adult Kidney Disease: Laboratory Testing (Lipid Profile): Percentage of patients aged 

18 years and older with a diagnosis of 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 

AMAPCPI 

AQA 

adopted/1

22 

Adult Kidney Disease: Blood Pressure Management: Percentage of patient visits for 

those patients aged 18 years and older with a diagnosis of CKD (stage 3, 4, or 5, not 

receiving Renal Replacement Therapy [RRT]) and documented proteinuria with a blood 

pressure < 130/80 mmHg OR ≥ 130/80 mmHg with a documented plan of care 

AMAPCPI 

AQA 

adopted/1

23 

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 

AMAPCPI 
CMS-1590-P 508 

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 ESA therapy AND have a 

Hemoglobin level > 12.0 g/dL 

 *This measures group is reportable through both claims and registry-based reporting 

TABLE 39: 2013 and Beyond Proposed Measures – Preventive Care Measures Group*

NQF/ 

PQRS Measure Title and Description Measure Developer 

0046/ 

39 

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 Xray absorptiometry (DXA) measurement ordered or performed at least once since age 60 

or pharmacologic therapy prescribed within 12 months 

AMAPCPI/ 

NCQA 

0098/ 

48 

Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence 

in Women Aged 65 Years and Older: Percentage of female patients aged 65 years and 

older who were assessed for the presence or absence of urinary incontinence within 12 

months 

AMAPCPI/ 

NCQA 

0041/ 

110 

Preventive Care and Screening: Influenza Immunization: Percentage of patients aged 

6 months and older who received an influenza immunization during the flu season 

(October 1 through March 31) 

AMAPCPI 

0043/ 

111 

Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and 

Older: Percentage of patients aged 65 years and older who have ever received a 

pneumococcal vaccine 

NCQA 

0031/ 

112 

Preventive Care and Screening: Screening Mammography: Percentage of women 

aged 40 through 69 years who had a mammogram to screen for breast cancer 

NCQA 

0034/ 

113 

Preventive Care and Screening: Colorectal Cancer Screening: Percentage of patients 

aged 50 through 75 years who received the appropriate colorectal cancer screening 

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 calculated BMI in the past six 

months or during the current visit documented in the medical record AND if the most 

recent BMI is outside of normal parameters, a follow-up plan is documented. Normal 

Parameters: Age 65 years and older BMI > 23and < 30; Age 18 – 64 years BMI > 18.5 

and < 25. 

CMS/ 

QIP 

AQA 

adopted/1

73 

Preventive Care and Screening: Unhealthy Alcohol Use – Screening: Percentage of 

patients aged 18 years and older who were screened for unhealthy alcohol use using a 

systematic screening method within 24 months 

AMAPCPI 

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 

AMAPCPI 

 *This measures group is reportable through both claims and registry-based reporting 

TABLE 40: 2013 and Beyond Proposed Measures – Coronary Artery Bypass Graft 

(CABG) Measures Group*

NQF/ 

PQRS Measure Title and Description Measure Developer 

0134/ 

43 

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 using an IMA graft 

STS 

0236/ 

44 

Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with 

Isolated CABG Surgery: Percentage of patients aged 18 years and older undergoing 

isolated CABG surgery 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 intubation > 24 

STS 
CMS-1590-P 509 

NQF/ 

PQRS Measure Title and Description Measure Developer 

hours 

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 

0115/ 

168 

Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration: Percentage of 

patients aged 18 years and older undergoing isolated CABG surgery who require a return to 

the operating room (OR) during the current hospitalization for mediastinal bleeding with or 

without tamponade, graft occlusion, valve dysfunction, or other cardiac reason 

STS 

0116/ 

169 

Coronary Artery Bypass Graft (CABG): Antiplatelet Medications at Discharge: 

Percentage of patients aged 18 years and older undergoing isolated CABG surgery who 

were discharged on antiplatelet medication 

STS 

0117/ 

170 

Coronary Artery Bypass Graft (CABG): Beta-Blockers Administered at Discharge: 

Percentage of patients aged 18 years and older undergoing isolated CABG surgery who 

were discharged on beta-blockers 

STS 

0118/ 

171 

Coronary Artery Bypass Graft (CABG): Anti-Lipid Treatment at Discharge: 

Percentage of patients aged 18 years and older undergoing isolated CABG surgery who 

were discharged on a statin or other lipid-lowering regimen 

STS 

*This measures group is reportable through registry-based reporting only 

TABLE 41: 2013 and Beyond Proposed Measures – Rheumatoid Arthritis (RA) Measures 

Group*

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 

AQA 

adopted/1

76 

Rheumatoid Arthritis (RA): Tuberculosis Screening: Percentage of patients aged 18 

years and older with a diagnosis of 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) 

AMAPCPI/ 

NCQA 

AQA 

adopted/1

77 

Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity: Percentage of 

patients aged 18 years and older with a diagnosis of RA who have an assessment and 

classification of disease activity within 12 months 

AMAPCPI/ 

NCQA 

AQA 

adopted 

/178 

Rheumatoid Arthritis (RA): Functional Status Assessment: Percentage of patients 

aged 18 years and older with a diagnosis of RA for whom a functional status assessment 

was performed at least once within 12 months 

AMAPCPI/ 

NCQA 

AQA 

adopted/1

79 

Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis: 

Percentage of patients aged 18 years and older with a diagnosis of RA who have an 

assessment and classification of disease prognosis at least once within 12 months 

AMAPCPI/ 

NCQA 

AQA 

adopted/1

80 

Rheumatoid Arthritis (RA): Glucocorticoid Management: Percentage of patients aged 

18 years and older with a diagnosis of 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 

AMAPCPI/ 

NCQA 

 *This measures group is reportable through both claims and registry-based reporting 
CMS-1590-P 510 

TABLE 42: 2013 and Beyond Proposed Measures – Perioperative Care Measures Group*

NQF/ 

PQRS Measure Title and Description Measure Developer 

0270/ 

20 

Perioperative Care: Timing of Antibiotic Prophylaxis – Ordering Physician: Percentage 

of surgical patients aged 18 years and older undergoing procedures with the indications for 

prophylactic parenteral antibiotics, who have an order for prophylactic parenteral antibiotic 

to be given within one hour (if fluoroquinolone or vancomycin, two hours), prior to the 

surgical incision (or start of procedure when no incision is required) 

AMAPCPI/ 

NCQA 

0268/ 

21 

Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation 

Cephalosporin: Percentage of surgical patients aged 18 years and older undergoing 

procedures with the indications for a first OR second generation cephalosporin prophylactic 

antibiotic, who had an order for cefazolin OR cefuroxime for antimicrobial prophylaxis 

AMAPCPI/ 

NCQA 

0271/ 

22 

Perioperative Care: Discontinuation of Prophylactic Antibiotics (Non-Cardiac 

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 

AMAPCPI/ 

NCQA 

0239/ 

23 

Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in 

ALL Patients): Percentage of 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 

AMAPCPI/ 

NCQA 

 *This measures group is reportable through both claims and registry-based reporting 

TABLE 43: 2013 and Beyond Proposed Measures – Back Pain Measures Group*

NQF/ 

PQRS Measure Title and Description Measure Developer 

0322/ 

148 

Back Pain: Initial Visit: The percentage of patients aged 18 through 79 years with a 

diagnosis of back pain or undergoing back surgery who had back pain and function assessed 

during the initial visit to the clinician for the episode of back pain 

NCQA 

0319/ 

149/ 

Back Pain: Physical Exam: Percentage of patients aged 18 through 79 years with a 

diagnosis of back pain or undergoing back surgery who received a physical examination at 

the initial visit to the clinician for the episode of back pain 

NCQA 

0314/ 

150 

Back Pain: Advice for Normal Activities: The percentage of patients aged 18 through 79 

years with a diagnosis of back pain or undergoing back surgery who received advice for 

normal activities at the initial visit to the clinician for the episode of back pain 

NCQA 

0313/ 

151 

Back Pain: Advice Against Bed Rest: The percentage of patients aged 18 through 79 years 

with a diagnosis of back pain or undergoing back surgery who received advice against bed 

rest lasting four days or longer at the initial visit to the clinician for the episode of back pain 

NCQA 

 *This measures group is reportable through both claims and registry-based reporting 

TABLE 44: 2013 and Beyond Proposed Measures – Hepatitis C Measures Group*

NQF/ 

PQRS Measure Title and Description Measure Developer 

0395/ 

84 

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 are receiving 

antiviral treatment for whom quantitative HCV RNA testing was performed within 6 months 

prior to initiation of antiviral treatment 

AMAPCPI 

0396/ 

85 

Hepatitis C: HCV Genotype Testing Prior to Treatment: Percentage of patients aged 18 

years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment 

for whom HCV genotype testing was performed prior to initiation of antiviral treatment 

AMAPCPI 

0397/ Hepatitis C: Antiviral Treatment Prescribed: Percentage of patients aged 18 years and AMA-
CMS-1590-P 511 

NQF/ 

PQRS Measure Title and Description Measure Developer 

86 older with a diagnosis of chronic hepatitis C who were prescribed at a minimum 

peginterferon and ribavirin therapy within the 12-month reporting period 

PCPI 

0398/ 

87 

Hepatitis C: HCV Ribonucleic Acid (RNA) Testing at Week 12 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 HCV RNA testing was performed at 

no greater than 12 weeks from the initiation of antiviral treatment 

AMAPCPI 

0401/ 

89 

Hepatitis C: Counseling Regarding Risk of Alcohol Consumption: Percentage of 

patients aged 18 years and older with a diagnosis of hepatitis C who were counseled about 

the risks of alcohol use at least once within 12-months 

AMAPCPI 

0394/ 

90 

Hepatitis C: Counseling Regarding Use of Contraception Prior to Antiviral Therapy: 

Percentage of female patients aged 18 through 44 years and all men aged 18 years and older 

with a diagnosis of chronic hepatitis C who are receiving antiviral treatment who were 

counseled regarding contraception prior to the initiation of treatment 

AMAPCPI 

0399/ 

183 

Hepatitis C: Hepatitis A Vaccination in Patients with HCV: Percentage of patients aged 

18 years and older with a diagnosis of hepatitis C who received at least one injection of 

hepatitis A vaccine, or who have documented immunity to hepatitis A 

AMAPCPI 

0400/ 

184 

Hepatitis C: Hepatitis B Vaccination in Patients with HCV: Percentage of patients aged 

18 years and older with a diagnosis of hepatitis C who received at least one injection of 

hepatitis B vaccine, or who have documented immunity to hepatitis B 

AMAPCPI 

 *This measures group is reportable through both claims and registry-based reporting 

TABLE 45: 2013 and Beyond Proposed Measures – Heart Failure (HF) Measures Group*

NQF/ 

PQRS Measure Title and Description Measure Developer 

0081/ 

5 

Heart Failure: 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 and LVSD 

(LVEF < 40%) who were prescribed ACE inhibitor or ARB therapy 

AMAPCPI/ 

ACCF/AH

A 

0083/ 

8 

Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction 

(LVSD): Percentage of patients aged 18 years and older with a diagnosis of heart failure 

who also have LVSD (LVEF < 40%) and who were prescribed beta-blocker therapy 

AMAPCPI/ 

ACCF/AH

A 

0079/ 

198 

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 result (of a recent or prior [any time in the past] LVEF assessment) is 

documented within a 12 month period 

AMAPCPI/ 

ACCF/AH

A 

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 

AMAPCPI 

 *This measures group is reportable through registry-based reporting only 

TABLE 46: 2013 and Beyond Proposed Measures – Coronary Artery Disease (CAD) 

Measures Group*

NQF/ 

PQRS Measure Title and Description Measure Developer 

0067/ 

6 

Coronary Artery Disease (CAD): Antiplatelet Therapy: Percentage of patients aged 18 

years and older with a diagnosis of coronary artery disease seen within a 12 month period 

who were prescribed aspirin or clopidogrel 

AMAPCPI/ 

ACCF/AH

A 

0074/ 

197 

Coronary Artery Disease (CAD): Lipid Control: Percentage of patients aged 18 years and 

older with a diagnosis of coronary artery disease seen within a 12 month period who have a 

LDL-C result < 100 mg/dL OR patients who have a LDL-C result ≥ 100 mg/dL and have a 

AMAPCPI/ 

ACCF/AH
CMS-1590-P 512 

NQF/ 

PQRS Measure Title and Description Measure Developer 

documented plan of care to achieve LDL-C <100 mg/dL, including at a minimum the 

prescription of a statin 

A 

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 

AMAPCPI 

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 

and with results of an evaluation of level of activity AND an assessment for the presence or

absence of anginal symptoms, with a plan of care to manage anginal symptoms, if present 

AMAPCPI/ 

ACCF/ 

AHA 

 *This measures group is reportable through registry-based reporting only 

TABLE 47: 2013 and Beyond Proposed Measures – Ischemic Vascular Disease (IVD) 

Measures Group*

NQF/ 

PQRS Measure Title and Description Measure Developer 

0073/ 

201 

Ischemic Vascular Disease (IVD): Blood Pressure Management Control: Percentage of 

patients aged 18 years and older with ischemic vascular disease (IVD) who had most recent 

blood pressure in control (less than 140/90 mmHg) 

NCQA 

0068/ 

204 

Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic: 

Percentage of patients aged 18 years and older with ischemic vascular disease (IVD) with 

documented use of aspirin or other antithrombotic 

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 

AMAPCPI 

0075/ 

241 

Ischemic Vascular Disease (IVD): Complete Lipid Panel and Low Density Lipoprotein 

(LDL-C) Control: Percentage of patients aged 18 years and older with Ischemic Vascular 

Disease (IVD) who received at least one lipid profile within 12 months and whose most 

recent LDL-C level was in control (less than 100 mg/dL) 

NCQA 

 *This measures group is reportable through both claims and registry-based reporting 

TABLE 48: 2013 and Beyond Proposed Measures – HIV/AIDS Measures Group*

NQF/ 

PQRS Measure Title and Description Measure 

Developer 

0404/ 

159 

HIV/AIDS: CD4+ Cell Count or CD4+ Percentage: Percentage of patients aged 6 months 

and older with a diagnosis of HIV/AIDS for whom a CD4+ cell count or CD4+ cell 

percentage was performed at least once every 6 months 

AMAPCPI/ 

NCQA 

0405/ 

160 

HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis: Percentage of 

patients aged 6 years and older with a diagnosis of HIV/AIDS and CD4+ cell count < 200 

cells/mm3 who were prescribed PCP prophylaxis within 3 months of low CD4+ cell count 

AMAPCPI/ 

NCQA 

0406/ 

161 

HIV/AIDS: Adolescent and Adult Patients with HIV/AIDS Who Are Prescribed Potent 

Antiretroviral Therapy: Percentage of patients with a diagnosis of HIV/AIDS aged 13 

years and older: who have a history of a nadir CD4+ cell count below 350/mm3 or who have 

a history of an AIDS- defining condition, regardless of CD4+ cell count; or who are 

pregnant, regardless of CD4+ cell count or age, who were prescribed potent antiretroviral 

therapy 

AMAPCPI/ 

NCQA 

0407/ 

162 

HIV/AIDS: HIV RNA Control After Six Months of Potent Antiretroviral Therapy: 

Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS who are 

receiving potent antiretroviral therapy, who have a viral load below limits of quantification 

after at least 6 months of potent antiretroviral therapy or patients whose viral load is not 

below limits of quantification after at least 6 months of potent antiretroviral therapy and 

AMAPCPI/ 

NCQA 
CMS-1590-P 513 

NQF/ 

PQRS Measure Title and Description Measure 

Developer 

have documentation of a plan of care 

0409/ 

205 

HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia and Gonorrhea: 

Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom 

chlamydia and gonorrhea screenings were performed at least once since the diagnosis of 

HIV infection 

AMAPCPI/ 

NCQA 

0413/ 

206 

HIV/AIDS: Screening for High Risk Sexual Behaviors: Percentage of patients aged 13 

years and older with a diagnosis of HIV/AIDS who were screened for high risk sexual 

behaviors at least once within 12 months 

AMAPCPI/ 

NCQA 

0415/ 

207 

HIV/AIDS: Screening for Injection Drug Use: Percentage of patients aged 13 years and 

older with a diagnosis of HIV/AIDS who were screened for injection drug use at least once 

within 12 months 

AMAPCPI/ 

NCQA 

0410/ 

208 

HIV/AIDS: Sexually Transmitted Disease Screening for Syphilis: Percentage of patients 

aged 13 years and older with a diagnosis of HIV/AIDS who were screened for syphilis at 

least once within 12 months 

AMAPCPI/ 

NCQA 

 *This measures group is reportable through registry-based reporting only 

TABLE 49: 2013 and Beyond Proposed Measures – Asthma Measures Group*

NQF/ 

PQRS Measure Title and Description Measure Developer 

0047/ 

53 

Asthma: Pharmacologic Therapy for Persistent Asthma: Percentage of patients aged 5 

through 50 years with a diagnosis of mild, moderate, or severe persistent asthma who were 

prescribed either the preferred long-term control medication (inhaled corticosteroid) or an 

acceptable alternative treatment 

AMAPCPI/ 

NCQA 

0001/ 

64 

Asthma: Assessment of Asthma Control: Percentage of patients aged 5 through 50 years 

with a diagnosis of asthma who were evaluated during at least one office visit within 12 

months for the frequency (numeric) of daytime and nocturnal asthma symptoms 

AMAPCPI/ 

NCQA 

N/A/ 

231 

Asthma: Tobacco Use: Screening - Ambulatory Care Setting: Percentage of patients (or 

their primary caregiver) aged 5 through 50 years with a diagnosis of asthma 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 

AMAPCPI/ 

NCQA 

N/A/ 

232 

Asthma: Tobacco Use: Intervention - Ambulatory Care Setting: Percentage of patients 

(or their primary caregiver) aged 5 through 50 years with a diagnosis of asthma who were 

identified as tobacco users (patients who currently use tobacco AND patients who do not 

currently use tobacco, but are exposed to second hand smoke in their home environment) 

who received tobacco cessation intervention at least once during the one-year measurement 

period 

AMAPCPI/ 

NCQA 

 *This measures group is reportable through both claims and registry-based reporting 

TABLE 50: 2013 and Beyond Proposed Measures – Chronic Obstructive Pulmonary 

Disease (COPD) Measures Group*

NQF/ 

PQRS Measure Title and Description Measure Developer 

0091/ 

51 

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 

AMAPCPI 

0102/ 

52 

Chronic Obstructive Pulmonary Disease (COPD): Bronchodilator Therapy: Percentage 

of patients aged 18 years and older with a diagnosis of COPD and who have an FEV1/FVC 

less than 70 percent and have symptoms who were prescribed an inhaled bronchodilator 

AMAPCPI 

0041/ 

110 

Preventive Care and Screening: Influenza Immunization: Percentage of patients aged 6 

months and older who received an influenza immunization during the flu season (October 1 

through March 31) 

AMAPCPI 

0043/ 

111 

Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and 

Older: Percentage of patients aged 65 years and older who have ever received a 

NCQA 
CMS-1590-P 514 

NQF/ 

PQRS Measure Title and Description Measure Developer 

 pneumococcal vaccine 

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 

AMAPCPI 

 *This measures group is reportable through both claims and registry-based reporting 

TABLE 51: 2013 and Beyond Proposed Measures – Inflammatory Bowel Disease (IBD) 

Measures Group*

NQF/ 

PQRS Measure Title and Description Measure Developer 

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 

AMAPCPI 

N/A/ 

269 

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 

AGA 

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 10mg/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 

N/A/ 

272 

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 

AGA 

N/A/ 

273 

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 

AGA 

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 Anti-TNF (Tumor Necrosis Factor) Therapy: Percentage of patients 

aged 18 years and older with a diagnosis of inflammatory bowel disease who had Hepatitis 

B Virus (HBV) status assessed and results interpreted within one year prior to receiving a 

first course of anti-TNF (tumor necrosis factor) therapy 

AGA 

 *This measures group is reportable through registry-based reporting only 

TABLE 52: 2013 and Beyond Proposed Measures – Sleep Apnea Measures Group*

NQF/ 

PQRS Measure Title and Description Measure 

Developer 

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 

AMAPCPI/ 
CMS-1590-P 515 

NQF/ 

PQRS Measure Title and Description Measure Developer 

an assessment of symptoms, including presence or absence of snoring and daytime 

sleepiness 

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 

AMAPCPI/ 

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 

AMAPCPI/ 

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 

AMAPCPI/ 

NCQA 

 *This measures group is reportable through registry-based reporting only 

TABLE 53: 2013 and Beyond Proposed Measures – Dementia Measures Group*

NQF/ 

PQRS Measure Title and Description Measure 

Developer 

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 patient’s 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 patient’s 

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 driving alternatives 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 

 *This measures group is reportable through claims and registry-based reporting 

TABLE 54: 2013 and Beyond Proposed Measures – Parkinson’s Disease Measures Group*
CMS-1590-P 516 

NQF/ 

PQRS Measure Title and Description Measure Developer 

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 than 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 

 *This measures group is reportable through registry-based reporting only 

TABLE 55: 2013 and Beyond Proposed Measures – Hypertension Measures Group*

NQF/ 

PQRS Measure Title and Description Measure Developer 

N/A/ 

295 

Hypertension: Appropriate Use of Aspirin or Other Antiplatelet or Anticoagulant 

Therapy: Percentage of patients aged 15 through 90 years old with a diagnosis of 

hypertension who were prescribed aspirin or other anticoagulant/antiplatelet therapy 

ABIM 

N/A/ 

296 

Hypertension: Complete Lipid Profile: Percentage of patients aged 15 through 90 years 

old with a diagnosis of hypertension who received a complete lipid profile within 24 

months 

ABIM 

N/A/ 

297 

Hypertension: Urine Protein Test: Percentage of patients aged 15 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 

ABIM 

N/A/ 

298 

Hypertension: Annual Serum Creatinine Test: Percentage of patients aged 15 through 

90 years old with a diagnosis of hypertension who had a serum creatinine test done within 

12 months 

ABIM 

N/A/ 

299 

Hypertension: Diabetes Mellitus Screening Test: Percentage of patients aged 15 

through 90 years old with a diagnosis of hypertension who had a diabetes screening test 

within 36 months 

ABIM 

N/A/ 

300 

Hypertension: Blood Pressure Control: Percentage of patients aged 15 through 90 years 

old with a diagnosis of hypertension who had most recent blood pressure level under 

control (at goal) 

ABIM 

N/A/ 

301 

Hypertension: Low Density Lipoprotein (LDL-C) Control: Percentage of patients aged 

15 through 90 years old with a diagnosis of hypertension who had most recent LDL 

cholesterol level under control (at goal) 

ABIM 

N/A/ 

302 

Hypertension: Dietary and Physical Activity Modifications Appropriately 

Prescribed: Percentage of patients aged 15 through 90 years old with a diagnosis of 

hypertension who received dietary and physical activity counseling at least once within 12 

ABIM 
CMS-1590-P 517 

NQF/ 

PQRS Measure Title and Description Measure Developer 

months 

 *This measures group is reportable through registry-based reporting only 

TABLE 56: 2013 and Beyond Proposed Measures – Cardiovascular Prevention Measures 

Group*

NQF/ 

PQRS Measure Title and Description 

Measure 

Developer 

0064/ 

2 

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

Percentage of patients aged 18 through 75 years with diabetes mellitus who had most 

recent LDL-C level in control (less than 100 mg/dL) 

NCQA 

0068/ 

204 

Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic: 

Percentage of patients aged 18 years and older with ischemic vascular disease (IVD) with 

documented use of aspirin or other antithrombotic 

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 

AMAPCPI 

0018/ 

236 

Hypertension (HTN): Controlling High Blood Pressure: Percentage of patients aged 

18 through 85 years of age who had a diagnosis of hypertension (HTN) and whose BP 

was adequately controlled (< 140/90 mmHg) 

NCQA 

0075/ 

241 

Ischemic Vascular Disease (IVD): Complete Lipid Panel and Low Density 

Lipoprotein (LDL-C) Control: Percentage of patients aged 18 years and older with 

Ischemic Vascular Disease (IVD) who received at least one lipid profile within 12 months 

and whose most recent LDL-C level was in control (less than 100 mg/dL) 

NCQA 

N/A/ 

317 

Preventive Care and Screening: Screening for High Blood Pressure: Percentage of 

patients aged 18 and older who are screened for high blood pressure 

CMS/ 

QIP 

 *This measures group is reportable through both claims and registry-based reporting 

TABLE 57: 2013 and Beyond Proposed Measures – Cataracts Measures Group*

NQF/ 

PQRS Measure Title and Description Measure 

Developer 

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 

AMAPCPI/ 

NCQA 

0564/ 

192 

Cataracts: Complications within 30 Days Following Cataract Surgery Requiring 

Additional Surgical Procedures: Percentage of patients aged 18 years and older with a 

diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified 

list of surgical procedures in the 30 days following cataract surgery which would indicate 

the occurrence of any of the following major complications: retained nuclear fragments, 

endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence 

AMAPCPI/ 

NCQA 

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 

 *This measures group is reportable through registry-based reporting only 
CMS-1590-P 518 

TABLE 58: 2013 and Beyond Proposed Measures – Oncology Measures Group* NQF/ PQRS 

Measure Title and Description 

Measure Developer 

0387/ 

71 

Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen 

Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer: 

Percentage of female patients aged 18 years and older with Stage IC 

through IIIC, ER or PR positive breast cancer who were prescribed 

tamoxifen or aromatase inhibitor (AI) during the 12-month reporting period 

AMAPCPI/ 

ASCO/

NCCN 

0385/ 

72 

Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients: 

Percentage of patients aged 18 years and older with Stage IIIA through IIIC 

colon cancer who are referred for adjuvant chemotherapy, prescribed 

adjuvant chemotherapy, or have previously received adjuvant chemotherapy 

within the 12-month reporting period 

AMAPCPI/ 

ASCO/

NCCN 

0041/ 

110 

Preventive Care and Screening: Influenza Immunization: Percentage of 

patients aged 6 months and older who received an influenza immunization 

during the flu season (October 1 through March 31) 

AMAPCPI 

0419/ 

130 

Documentation of Current Medications in the Medical Record: 

Percentage of specified visits for patients aged 18 years and older for which 

the eligible professional attests to documenting a list of current medications 

to the best of his/her knowledge and ability. This list must include ALL 

prescriptions, over-the-counters, herbals, vitamin/mineral/dietary 

(nutritional) supplements AND must contain the medications’ name, 

dosage, frequency and route 

CMS/ 

QIP 

0384/ 

143 

Oncology: Medical and Radiation – Pain Intensity Quantified: 

Percentage of patient visits, regardless of patient age, with a diagnosis of 

cancer currently receiving chemotherapy or radiation therapy in which pain 

intensity is quantified 

AMAPCPI 

0383/ 

144 

Oncology: Medical and Radiation – Plan of Care for Pain: Percentage of 

patient visits, regardless of patient 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 

AMAPCPI 

0386/ 

194 

Oncology: Cancer Stage Documented: Percentage of patients, regardless 

of age, with a diagnosis of breast, colon, or rectal cancer who are seen in the 

ambulatory setting who have a baseline AJCC cancer stage or 

documentation that the cancer is metastatic in the medical record at least 

once within 12 months 

AMAPCPI/ 

ASCO 

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 

AMAPCPI 

 *This measures group is reportable through registry-based reporting only 

TABLE 59: 2014 and Beyond Proposed Measures – Osteoporosis Measures Group*

NQF/ 

PQRS Measure Title Measure 

Developer 
CMS-1590-P 519 

NQF/ 

PQRS Measure Title Measure Developer 

0046/ 

39 

Osteoporosis: 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 

0049/ 

41 

Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years and 

Older: Percentage of patients aged 50 years and older with a diagnosis of osteoporosis 

who were prescribed pharmacologic therapy within 12 months 

AMA 

AQA 

Selected 

/154 

Falls: Risk Assessment for Falls: Percentage of patients aged 65 years and older with a 

history of falls who had a risk assessment for falls completed within 12 months 

NCQA 

AQA 

Selected 

/155 

Falls: Plan of Care for Falls: 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 

NCQA 

N/A / 

TBD 

Osteoporosis: Status of Participation in Weight-Bearing Exercise and Weightbearing Exercise Advice: Percentage of patients aged 18 and older with a diagnosis of 

osteoporosis, osteopenia, or prior low impact fracture; women age 65 and older; or men 

age 70 and older whose status regarding participation in weight-bearing exercise was 

documented and for those not participating regularly who received advice within 12 

months to participate in weight-bearing exercise

ABIM 

N/A / 

TBD 

Osteoporosis: Current Level of Alcohol Use and Advice on Potentially Hazardous 

Drinking Prevention: Percentage of patients aged 18 and older with a diagnosis of 

osteoporosis, osteopenia, or prior low impact fracture; women age 65 and older; or men 

age 70 and older whose current level of alcohol use was documented and for those 

engaging in potentially hazardous drinking who received counseling within 12 months

ABIM 

N/A / 

TBD 

Osteoporosis: Screen for Falls Risk Evaluation and Complete Falls Risk Assessment 

and Plan of Care: Percentage of patients aged 18 and older with a diagnosis of 

osteoporosis, osteopenia, or prior low impact fracture; women age 65 and older; or men 

age 70 and older who had a screen for falls risk evaluation within the past 12 months and 

for those reported as having a history of two or more falls, or fall-related injury who had 

a complete risk assessment for falls and a falls plan of care within the past 12 months 

ABIM 

N/A / 

TBD 

Osteoporosis: Dual-Emission X-ray Absorptiometry (DXA) Scan: Percentage of 

patients aged 18 and older with a diagnosis of osteoporosis, osteopenia, or prior low 

impact fracture; women age 65 and older; or men age 70 and older who had a DXA scan 

and result documented

ABIM 

N/A / 

TBD 

Osteoporosis: Calcium Intake Assessment and Counseling: Percentage of patients

aged 18 and older with a diagnosis of osteoporosis, osteopenia, or prior low impact 

fracture; women age 65 and older; or men age 70 and older who had calcium intake 

assessment and counseling at least once within 12 months

ABIM 

N/A / 

TBD 

Osteoporosis: Vitamin D Intake Assessment and Counseling: Percentage of patients

aged 18 and older with a diagnosis of osteoporosis, osteopenia, or prior low impact 

fracture; women age 65 and older; or men age 70 and older who had vitamin D intake 

assessment and counseling at least once within 12 months

ABIM 

N/A / 

TBD 

Osteoporosis: Pharmacologic Therapy: Percentage of patients aged 18 and older with 

a diagnosis of osteoporosis, osteopenia, or prior low impact fracture; women age 65 and 

older; or men age 70 and older who were prescribed pharmacologic therapy approved by 

the Food and Drug Administration

ABIM 

 *This measures group is reportable through claims and registry-based reporting 

TABLE 60: 2014 and Beyond Proposed Measures – Total Knee Replacement Measures 

Group*

NQF/ 

PQRS Measure Title Measure 

Developer 
CMS-1590-P 520 

NQF/ 

PQRS Measure Title Measure 

Developer 

N/A / 

TBD 

Total Knee Replacement: Coordination of Post Discharge Care: Percentage of patients 

undergoing total knee replacement who received written instructions for post discharge care 

including all the following: post discharge physical therapy, home health care, post 

discharge deep vein thrombosis (DVT) prophylaxis and follow-up physician visits

AAHKS/A

MA-PCPI 

N/A / 

TBD 

Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk 

Evaluation: Percentage of patients 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 (DVT), 

pulmonary embolism (PE), myocardial infarction (MI), arrhythmia and stroke

AAHKS/A

MA-PCPI 

N/A / 

TBD 

Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet: 

Percentage of patients undergoing a total knee replacement who had the prophylactic 

antibiotic completely infused prior to the inflation of the proximal tourniquet

AAHKS/A

MA-PCPI 

N/A / 

TBD 

Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report: 

Percentage of patients undergoing total knee replacement whose operative report identifies 

the prosthetic implant specifications including the prosthetic implant manufacturer, the 

brand name of prosthetic implant and the size of prosthetic implant

AAHKS/A

MA-PCPI 

 *This measures group is reportable through and registry-based only 

TABLE 61: 2014 and Beyond Proposed Measures – Radiation Dose Optimization Measures 

Group*

NQF/ 

PQRS Measure Title Measure Developer 

TBD/ 

TBD 

Radiation Dose Optimization: Utilization of a Standardized Nomenclature for 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 (e.g., RadLex®) and the standardized nomenclature is used in institutions 

computer systems 

AMAPCPI 

TBD/ 

TBD 

Radiation Dose Optimization: Cumulative Count of Potential High Dose Radiation 

Imaging Studies: Computed Tomography (CT) Scans and Cardiac Nuclear Medicine 

Scans: Percentage of CT and cardiac nuclear medicine (myocardial perfusion) imaging 

reports for all patients, regardless of age, that document a count of known previous CT 

studies (any type of CT) and cardiac nuclear medicine (myocardial perfusion studies) studies 

that the patient has received in the 12-month period prior to the current study

AMAPCPI 

TBD/ 

TBD 

Radiation Dose Optimization: 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 

AMAPCPI 

TBD/ 

TBD 

Radiation Dose Optimization: Images Available for Patient Follow-up and 

Comparison Purposes: Percentage of final reports for imaging studies performed for all 

patients, regardless of age, which document that Digital Imaging and Communications in 

Medicine (DICOM) format image data are available reciprocally to non-affiliated external 

entities on a secure, media free, searchable basis with patient authorization for at least a 12-

month period after the study 

AMAPCPI 

TBD/ 

TBD 

Radiation Dose Optimization: Search for Prior Imaging Studies Through a Secure, 

Authorized, Media-Free, Shared Archive: Percentage of final reports of imaging 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 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 

AMAPCPI 

 *This measures group is reportable through both claims and registry-based reporting 
CMS-1590-P 521 

TABLE 62: 2014 and Beyond Proposed Measures – Preventive Cardiology Measures 

Group*

NQF/ 

PQRS Measure Title Measure 

Developer 

N/A/ 

TBD 

Preventive Cardiology Composite: Blood Pressure at Goal: Percentage of patients in the 

sample whose most recent blood pressure reading was at goal 

ABIM 

N/A/ 

TBD 

Preventive Cardiology Composite: Low Density Lipids (LDL) Cholesterol at Goal: 

Percentage of patients in the sample whose LDL cholesterol is considered to be at goal, 

based upon their coronary heart disease (CHD) risk factors

ABIM 

N/A/ 

TBD 

Preventive Cardiology Composite: Timing of Lipid Testing Complies with Guidelines: 

Percentage of patients in the sample whose timing of lipid testing complies with guidelines 

(lipid testing performed in the preceding 12-month period (with a three-month grace period) 

for patients with known coronary heart disease (CHD) or CHD risk equivalent (prior 

myocardial infarction (MI), other clinical CHD, symptomatic carotid artery disease, 

peripheral artery disease, abdominal aortic aneurysm, diabetes mellitus); or in the preceding 

24-month period (with a three-month grace period) for patients with > 2 risk factors for 

CHD (smoking, hypertension, low high density lipid (HDL), men > 45 years, women > 55 

years, family history of premature CHD; HDL > 60 mg/dL acts as a negative risk factor); or 

in the preceding 60-month period (with a three-month grace period) for patients with < 1 

risk factor for CHD) 

ABIM 

N/A/ 

TBD 

Preventive Cardiology Composite: Diabetes Documentation or Screen Test: Percentage 

of patients in the sample who had a screening test for type 2 diabetes or had a diagnosis of 

diabetes 

ABIM 

N/A/ 

TBD 

Preventive Cardiology Composite: Correct Determination of Ten-Year Risk for 

Coronary Death or Myocardial Infarction (MI): Number of patients in the sample whose 

ten-year risk of coronary death or MI is correctly assessed and documented 

ABIM 

N/A/ 

TBD 

Preventive Cardiology Composite: Counseling for Diet and Physical Activity: 

Percentage of patients in the sample who received dietary and physical activity counseling 

ABIM 

N/A/ 

TBD 

Preventive Cardiology Composite: Appropriate Use of Aspirin or Other 

Antiplatelet/Anticoagulant Therapy: Percentage of patients in the sample who are: 1) 

taking aspirin or other anticoagulant/antiplatelet therapy, or 2) under age 30, or 3) age 30 or 

older and who are documented to be at low risk. Low-risk patients include those who are 

documented with no prior coronary heart disease (CHD) or CHD risk equivalent (prior 

myocardial infarction (MI), other clinical CHD, symptomatic carotid artery disease, 

peripheral artery disease, abdominal aortic aneurysm, diabetes mellitus) and whose ten-year 

risk of developing CHD is < 10% 

ABIM 

N/A/ 

TBD 

Preventive Cardiology Composite: Smoking Status and Cessation Support: Percentage 

of patients in the sample whose current smoking status is documented in the chart, and if 

they were smokers, were documented to have received smoking cessation counseling during 

the reporting period 

ABIM 

 *This measures group is reportable through both claims and registry-based reporting 

 We invite public comment on the proposed Physician Quality Reporting System 

measures groups. 

(5) Proposed Physician Quality Reporting System Measures for Eligible Professionals and 

Group Practices that Report Using Administrative Claims for the 2015 and 2016 Payment 

Adjustments 

 We are proposing the following measures in Table 63 for eligible professionals and group 
CMS-1590-P 522 

practices that report using administrative claims for the 2015 and 2016 payment adjustments. 

Our proposals on how to attribute beneficiaries to groups of physicians that elect the 

administrative claims option are discussed in the value-based payment modifier in section K. 

below. We considered all of the measures included in the program year 2010 individual 

Physician Feedback reports that can be calculated using administrative claims but are proposing 

only a subset of the measures that were included in the program year 2010 individual Physician 

Feedback reports. We are proposing this subset of measures for both the PQRS payment 

adjustment and the value-based modifier because we believe these measures are clinically 

meaningful, focus on highly prevalent conditions among beneficiaries, have the potential to 

differentiate physicians, and be statistically reliable. To the extent that the value-based payment 

modifier finalizes other measures from the 2010 individual Physician Feedback reports that are 

listed in Table 65, it would be our intent to finalize those additional measures as well for 

purposes of the 2015 and 2016 PQRS payment adjustments so that the two programs can be 

aligned. 

 As specified in Table 63, we are proposing 19 measures. Of these 19 proposed measures, 

17 of these measures are NQF-endorsed and therefore satisfying section 1848(k)(2)(C)(i) if the 

Act. With respect to the 2 measures that are not NQF-endorsed, “Potentially Harmful DrugDisease Interactions in the Elderly” and “Diabetes: LDL-C Screening ,” we are exercising our 

exception authority under section 1848(k)(2)(C)(ii) of the Act to propose these measures for 

inclusion in the PQRS administrative claims measure set. Both of these measures are relevant as 

they address care coordination by measuring the amount of time a patient has been readmitted 

and/or where their status is in the healthcare continuum following hospitalization. The utilization 

of the administrative claims measures will allow PQRS to implement different reporting options 
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which capture a wider venue of participants without using the traditional methods of reporting 

and eliminate the potential payment adjustment for non-participators. 

TABLE 63: Proposed Measures for Eligible Professionals and Group Practices Who 

Report Using Administrative Claims for the 2015 and 2016 PQRS Payment Adjustment 

NQF 

Number 

Measure Title Measure 

Steward 

Domain of 

Care 

0279 Bacterial Pneumonia 

The number of admissions for bacterial pneumonia per 100,000 population.

AHRQ Care 

Coordination 

0281 UTI 

The number of discharges for urinary tract infection per 100,000 

population Age 18 Years and Older in a one year time period

AHRQ Care 

Coordination 

0280 Dehydration 

The number of admissions for dehydration per 100,000 population.

AHRQ Care 

Coordination 

 Composite of Chronic Prevention Quality Indicators N/A 

 Diabetes Composite 

0638 Uncontrolled diabetes 

The number of discharges for uncontrolled diabetes per 100,000 population 

Age 18 Years and Older in a one year time period.

AHRQ Care 

Coordination 

0272 Short Term Diabetes complications 

The number of discharges for diabetes short-term complications per 

100,000 Age 18 Years and Older population in a one year period.

AHRQ Care 

Coordination 

0274 Long term diabetes complications 

The number of discharges for long-term diabetes complications per 

100,000 population Age 18 Years and in a one year time period. 

AHRQ Care 

Coordination 

0285 Lower extremity amputation for diabetes 

The number of discharges for lower-extremity amputation among patients 

with diabetes per 100,000 population Age 18 Years in a one year time 

period.

AHRQ Care 

Coordination 

0275 COPD 

The number of admissions for chronic obstructive pulmonary disease 

(COPD) per 100,000 population.

AHRQ Care 

Coordination 

0277 Heart Failure 

Percent of the population with admissions for CHF.

AHRQ Care 

Coordination 

N/A All Cause Readmission 

The rate of provider visits within 30 days of discharge from an acute care 

hospital per 1,000 discharges among eligible beneficiaries assigned. 

CMS Care 

Coordination 

N/A 30 Day Post Discharge Visit 

The rate of provider visits within 30 days of discharge from an acute care 

hospital per 1,000 discharges among eligible beneficiaries assigned.

CMS Care 

Coordination 

0576 Follow-Up After Hospitalization for Mental Illness 

Percentage of discharges for patients who were hospitalized for treatment of selected mental 

health disorders and who had an outpatient visit, an intensive outpatient encounter, or partial 

hospitalization with a mental health practitioner

NCQA Care 

Coordination 

0021 Annual Monitoring for Beneficiaries on Persistent Medications 

Percentage of patients 18 years of age and older who received at least 180 treatment days of 

ambulatory medication therapy for a select therapeutic agent during the measurement year and 

at least one therapeutic monitoring event for the therapeutic agent in the measurement year.

NCQA Patient 

Safety 

0555 Lack of Monthly INR Monitoring for Beneficiaries on Warfarin 

Average percentage of 40-day intervals in which Part D beneficiaries with claims for warfarin 

do not receive an INR test during the measurement period.

CMS Patient 

Safety 

0577 Use of Spirometry Testing to Diagnose COPD 

Percentage of patients at least 40 years old who have a new diagnosis or newly active chronic 

obstructive pulmonary disease (COPD) who received appropriate spirometry testing to 

confirm the diagnosis.

NCQA Clinical Care 

0549 Pharmacotherapy Management of COPD Exacerbation 

Percentage of chronic obstructive pulmonary disease (COPD) exacerbations for patients 40 

NCQA Clinical Care
CMS-1590-P 524 

NQF 

Number 

Measure Title Measure 

Steward 

Domain of 

Care 

years of age and older who had an acute inpatient discharge or ED encounter between January 

1–November 30 of the measurement year and were dispensed appropriate medications

0543 Statin Therapy for Beneficiaries with Coronary Artery Disease 

Medication Possession Ratio (MPR) for statin therapy for individuals over 18 years of age 

with coronary artery disease.

CMS Clinical Care

0583 Lipid Profile for Beneficiaries Who Started Lipid-Lowering 

Medications 

Percentage of patients age 18 or older starting lipid-lowering medication during the 

measurement year who had a lipid panel checked within 3 months after starting drug therapy

Resolution 

Health 

Clinical Care

0053 Osteoporosis Management in Women ≥ 67 Who Had a Fracture 

Percentage of women 67 years and older who suffered a fracture and who had either a bone 

mineral density (BMD) test or prescription for a drug to treat or prevent osteoporosis in the six 

months after the date of fracture.

NCQA Clinical Care

0055 Dilated Eye Exam for Beneficiaries ≤ 75 with Diabetes 

Percentage of adult patients with diabetes aged 18-75 years who received a dilated eye exam 

by an ophthalmologist or optometrist during the measurement year, or had a negative retinal 

exam (no evidence of retinopathy) by an eye care professional in the year prior to 

themeasurement year.

NCQA Clinical Care

0057 HbA1c Testing for Beneficiaries ≤ 75 with Diabetes 

Percentage of adult patients with diabetes aged 18-75 years receiving one or more A1c test(s) 

per year.

NCQA Clinical Care

0062 Urine Protein Screening for Beneficiaries ≤ 75 with Diabetes 

Percentage of adult diabetes patients aged 18-75 years with at least one test nephropathy 

screening test during the measurement year or who had evidence existing nephropathy 

(diagnosis of nephropathy or documentation of microalbuminuria or albuminuria).

NCQA Clinical Care

0063 Lipid Profile for Beneficiaries ≤ 75 with Diabetes 

Percentage of adult patients with diabetes aged 18-75 who had an LDL-C test performed 

during the measurement year.

NCQA Clinical Care

0075 Lipid Profile for Beneficiaries with Ischemic Vascular Disease 

Percentage of patients 18 years of age and older who were discharged alive for acute 

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

interventions (PCI) from January 1–November 1 of the year prior to the measurement year, or 

who had a diagnosis of ischemic vascular disease (IVD) during the measurement year and the 

year prior to measurement year, who had a complete lipid profile during the measurement 

year.

NCQA Clinical Care

0105 Antidepressant Treatment for Depression 

Percentage of discharges for patients who were hospitalized for treatment of selected mental 

health disorders and who had an outpatient visit, an intensive outpatient encounter, or partial 

hospitalization with a mental health practitioner.

NCQA Clinical Care

0031 Breast Cancer Screening for 

Women ≤ 69 

Percentage of eligible women 40-69 who receive a mammogram in during the measurement 

year or in the year prior to the measurement year.

NCQA Clinical Care 

 We invite public comment on the proposed measures for eligible professionals and group 

practices that report using administrative claims. We seek comment on whether these are these 

proposed measures.

7. Proposed Maintenance of Certification Program Incentive: Proposed Self-Nomination 

Process for Entities Wishing to be Qualified for the 2013 and 2014 Maintenance of Certification 

Program Incentives 

We propose that new and previously qualified entities wishing to become qualified to 
CMS-1590-P 525 

provide their members with an opportunity to earn the 2013 and/or 2014 Maintenance of 

Certification Program incentives undergo a self-nomination and qualification process. Once 

qualified, the entity would be able to submit data on behalf of its eligible professionals. 

For the self-nomination process, we propose that an entity wishing to be qualified for the 

2013 and/or 2014 Maintenance of Certification Program incentive would be required to submit a 

self-nomination statement containing all of the following information via the web: 

● Provide detailed information regarding the Maintenance of Certification Program with 

reference to the statutory requirements for such program. 

● Indicate the organization sponsoring the Maintenance of Certification Program, and 

whether the Maintenance of Certification Program is sponsored by an American Board of 

Medical Specialties (ABMS) board. If not an ABMS board, indicate whether and how the 

program is substantially equivalent to the ABMS Maintenance of Certification Program process. 

● Indicate that the program is in existence as of January 1 the year prior to the year in 

which the entity seeks to be qualified for the Maintenance of Certification Program incentive. 

For example, to be qualified for the 2013 Maintenance of Certification Program incentive, the 

entity would be required to be in existence by January 1, 2012. 

● Indicate that the program has at least one (1) active participant. 

● The frequency of a cycle of Maintenance of Certification for the specific Maintenance 

of Certification Program of the sponsoring organization, including what constitutes "more 

frequently" for both the Maintenance of Certification Program itself and the practice assessment 

for the specific Maintenance of Certification Program of the sponsoring organization. 

● Confirmation from the board that the practice assessment will occur and be completed 

in the year the physician is participating in the Maintenance of Certification Program Incentive. 

● What was, is, or will be the first year of availability of the Maintenance of 
CMS-1590-P 526 

Certification Program practice assessment for completion by an eligible professional. 

● What data is collected under the patient experience of care survey and how this 

information would be provided to CMS. 

● Describe how the Maintenance of Certification program monitors that an eligible 

professional has implemented a quality improvement process for their practice. 

● Describe the methods, and data used under the Maintenance of Certification Program, 

and provide a list of all measures used in the Maintenance of Certification Program for the year 

prior to which the entity seeks to be qualified for the Maintenance of Certification Program 

incentive (for example, measures used in 2012 for the 2013 Maintenance of Certification 

Program incentive), including the title and descriptions of each measure, the owner of the 

measure, whether the measure is NQF endorsed, and a link to a website containing the detailed 

specifications of the measures, or an electronic file containing the detailed specifications of the 

measures. 

For the qualification process, we propose that an entity must meet all of the following 

requirements to be considered for qualification for purposes of the 2013 and 2014 Maintenance 

of Certification Program incentives: 

● The name, NPI and applicable TINs of eligible professionals who would like to 

participate for the 2013 and/or 2014 Maintenance of Certification Program incentives. 

● Attestation from the board that the information provided to CMS is accurate and 

complete. 

● The board has signed documentation from eligible professional(s) that the eligible 

professional wishes to have the information released to us. 

● Information from the patient experience of care survey. 

● Information certifying the eligible professional has participated in a Maintenance of 
CMS-1590-P 527 

Certification Program for a year, “more frequently” than is required to qualify for or maintain 

board certification status, including the year the physician met the board certification 

requirements for the Maintenance of Certification Program, and the year the eligible professional 

participated in the Maintenance of Certification Program “more frequently” than is required to 

maintain or qualify for board certification. 

● Information certifying the eligible professional has completed the Maintenance of 

Certification Program practice assessment at least one time each year the eligible professional 

participates in the Maintenance of Certification Program Incentive. 

We are proposing this self-nomination and qualification process because the process is 

identical to the self-nomination and qualification process finalized for the 2011 and 2012 

Maintenance of Certification Program incentives and we believe such requirements remain 

appropriate. As the incentives only run through 2014, we believe it is important to keep the 

requirements consistent with what has been required for the 2011 and 2012 Maintenance of 

Certification Program incentives. We invite public comment on our proposed self-nomination 

and qualification process for entities who wish to be qualified for the 2013 and 2014 

Maintenance of Certification Program incentive. 

8. Informal Review 

 We established an informal review process for 2012 and beyond in the CY 2012 

Medicare PFS final rule (76 FR 73390). In this proposed rule, we address the additional 

parameters of eligible professionals and group practices subject to a PQRS payment adjustment 

requesting an informal review. For eligible professionals and group practices that are subject to 

the payment adjustments that wish to request an informal review, in addition to the requirements 

we previously established, we propose the following: 

● For eligible professionals and group practices wishing to submit an informal review 
CMS-1590-P 528 

related to the payment adjustment, we propose 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. We believe this 

deadline provides ample time for eligible professionals and group practices to discover that their 

respective claims are being adjusted due to the payment adjustment. 

● Where we find that the eligible professional or group practice did satisfactorily report 

for the payment adjustment, we propose to cease application of the payment adjustment and 

reprocess all claims that have been erroneously adjusted to date. 

 We invite public comment on our proposals for the PQRS informal review process. 

H. The Electronic Prescribing (eRx) Incentive Program

 We established the requirements for the 2013 and 2014 eRx Incentive Program in the CY 

2012 Medicare PFS final rule (76 FR 73393). This section contains additional proposals for the 

2013 and 2014 eRx Incentive Program. 

1. Proposed Alternative Self-Nomination Process for Certain Group Practices Under the eRx 

GPRO 

 In the CY 2012 Medicare PFS final rule (76 FR 73394), we established that a group 

practice wishing to participate in the eRx Incentive Program under the eRx GPRO must selfnominate via the web. However, we propose an alternative submission mechanism for selfnomination by groups participating in the MSSP, Pioneer ACO, or PGP Demonstration. 

Specifically, we propose that the participating TINs within these groups that wish to participate 

in the eRx Incentive Program using the eRx GPRO must submit a self-nomination statement by 

sending a letter indicating its intent to participate in the eRx Incentive Program under the eRx 
CMS-1590-P 529 

GPRO. We also propose that the group practice must submit an XML file describing the eligible 

professionals included in the group practice. We are proposing this alternative submission 

mechanism for group practices that are participating as groups in the MSSP, Pioneer ACO, or 

PGP Demonstration because it is not technically feasible for CMS to receive this information 

from these group practices via the web. We invite public comment on this proposed alternative 

mechanism for submitting self-nomination statements and the XML file for the types of group 

practices identified above that want to participate in the eRx Incentive Program using the eRx 

GPRO. 

2. The 2013 Incentive: Proposed Criterion for Being a Successful Electronic Prescriber for 

Groups Comprised of 2-24 Eligible Professionals Selected to Participate under the eRx GPRO 

As stated in section III.G, we are proposing to modify §414.90(b) to define a group 

practice as “a single Tax Identification Number (TIN) with 2 or more eligible professionals, as 

identified by their individual National Provider (NPI), who have reassigned their Medicare 

billing rights to the TIN.” Under §414.92(b), we define a group practice as a practice that 

indicates its desire to participate in the eRx group practice option and meets the definition of 

group practice according to the PQRS at §414.90(b), or a group practice participating in certain 

other Medicare programs (for example, PGP demonstration, Shared Savings Program). 

Therefore, since we are proposing to change the minimum group practice size from 25 to 2, we 

are proposing to add another criterion for being a successful electronic reporter under the 

program for the 2013 Incentive (for the other criteria we previously adopted for the ERx GPRO 

Reporting Option, please see 76 FR 73407). Specifically, we are proposing the following 

criterion for being a successful electronic prescriber for group practices participating in the eRx 

GPRO comprised of 2-24 eligible professionals for purposes of the 2013 eRx incentive: report 

the electronic prescribing measure’s numerator code during a denominator-eligible encounter for 
CMS-1590-P 530 

at least 225 times during the 12-month 2013 incentive reporting period (January 1, 2013—

December 31, 2013). We are proposing lower criterion for group practices participating under 

the eRx GPRO with 2-24 eligible professionals because we understand that their smaller sizes 

necessitate a lower reporting threshold. We chose this reporting threshold because this reporting 

threshold is familiar to group practices, as this was the threshold established for group practices 

comprised of 11-25 eligible professionals that participated in the GPRO II in 2010 (75 FR 

73509). We invite public comment on our proposed criterion for being a successful electronic 

prescriber for the 2013 incentive for groups comprised of 2-24 eligible professionals. 

3. The 2014 Payment Adjustment: Proposed Criterion for Being a Successful Electronic 

Prescriber for Groups Comprised of 2-24 Eligible Professionals Selected to Participate under the 

eRx GPRO 

As stated in section III.G, we are proposing to modify §414.90(b) to define a group practice as “a 

single Tax Identification Number (TIN) with 2 or more eligible professionals, as identified by their 

individual National Provider (NPI), who have reassigned their Medicare billing rights to the 

TIN.” Under §414.92(b), we define a group practice for the purposes of being able to participate 

under the eRx GPRO as a practice that indicates its desire to participate in the eRx group practice 

option and either meets the definition of group practice according to the PQRS at §414.90(b) or 

is a group practice participating in certain other Medicare programs (for example, PGP 

demonstration, Shared Savings Program). Therefore, since we are proposing to change the 

minimum group practice size from 25 to 2, we are proposing to add another criterion for being a 

successful electronic reporter under the program for the 2014 payment adjustment (for the other 

criteria we previously adopted for the ERx GPRO Reporting Option, please see 76 FR 73412-

73414). Specifically, we are proposing the following criterion for being a successful electronic 

prescriber for purposes of the 2014 payment adjustment for group practices comprised of 2-24 
CMS-1590-P 531 

eligible professionals participating under the eRx GPRO: Report the electronic prescribing 

measure's numerator code at least 225 times for the 6-month 2014 payment adjustment reporting 

period (January 1, 2013—June 30, 2013). We are proposing this lower criterion for group 

practices participating under the eRx GPRO with 2-24 eligible professionals because we 

understand that their smaller sizes necessitate a lower reporting threshold. In addition, we note 

that this reporting threshold is familiar to group practices, as this was the threshold established 

for group practices comprised of 11-25 eligible professionals that participated in the GPRO II in 

2010 (75 FR 73509). We invite public comment on the proposed criterion for being a successful 

electronic prescriber for the 2014 eRx payment adjustment for the 6-month payment adjustment 

reporting period for group practices composed of 2-24 eligible professionals. 

4. Proposed Analysis for the Claims-based Reporting Mechanism 

 We understand that, in certain instances, it is permissible for an eligible professional to 

have their Medicare Part B claims reprocessed. Please note that, if a Medicare Part B claim is 

reopened for reprocessing, the reprocessing of claim does not allow an eligible professional to 

attach a G-code on a claim for purposes of reporting quality measures, such as the electronic 

prescribing measure. Therefore, we are proposing to modify §414.92 to indicate that claims may 

not be reprocessed for the sole purpose of attaching a reporting G-code on a claim. 

5. Proposed Significant Hardship Exemptions 

 Section 1848(a)(5)(B) of the Act provides that the Secretary may, on a case-by-case 

basis, exempt an eligible professional from the application of the payment adjustment, if the 

Secretary determines, subject to annual renewal, that compliance with the requirement for being 

a successful electronic prescriber would result in a significant hardship. In the CY 2012 final 

rule with comment period, we finalized, as set forth at §414.92(c)(2)(ii)(B), four circumstances 

under which an eligible professional or eRx GPRO can request consideration for a significant 
CMS-1590-P 532 

hardship exemption for the 2013 and 2014 eRx payment adjustments (76 FR 73413): 

• The eligible professional or group practice practices in a rural area with limited high speed 

internet access. 

• The eligible professional or group practice practices in an area with limited available 

pharmacies for electronic prescribing. 

• The eligible professional or group practice is unable to electronically prescribe due to local, 

state, or Federal law or regulation. 

• The eligible professional or group practice has limited prescribing activity, as defined by an 

eligible professional generating fewer than 100 prescriptions during a 6-month reporting 

period. 

 We have received feedback from stakeholders requesting significant hardship exemptions 

from application of the eRx payment adjustment based on participation in the EHR Incentive 

Program, a program which requires a certain level of electronic prescribing activity. Under the 

EHR Incentive Program, eligible professionals4

 may receive incentive payments beginning in 

CY 2011 for successfully demonstrating “meaningful use” of Certified EHR Technology 

(CEHRT) and will be subject to payment adjustments beginning in CY 2015 for failure to 

demonstrate meaningful use. For further explanation of the statutory authority and regulations 

for the EHR Incentive Program, we refer readers to the July 28, 2010 final rule titled “Medicare 

and Medicaid Programs; Electronic Health Record Incentive Program; Final Rule,” (75 FR 

44314). As a result of such feedback, we believe that in certain circumstances it may be a 

significant hardship for eligible professionals and group practices who are participants of the 

EHR Incentive Program to comply with the successful electronic prescriber requirements of the 

eRx Incentive Program. Therefore, we are proposing to revise the regulation at 

 

4

 “Eligible professional” is defined for the EHR Incentive Program at 42 C.F.R. §§ 495.4, 495.100, and 495.304. 
CMS-1590-P 533 

§414.92(c)(2)(ii)(B) to add the following two additional significant hardship exemption 

categories for the 2013 and 2014 eRx payment adjustments: 

• Eligible professionals or group practices who achieve meaningful use during certain eRx 

payment adjustment reporting periods. 

• Eligible professionals or group practices who demonstrate intent to participate in the EHR 

Incentive Program and adoption of Certified EHR Technology. 

A. Eligible professionals or group practices who achieve meaningful use during certain 2013 

and 2014 eRx payment adjustment reporting periods. 

 Under Stage 1 of meaningful use for the EHR Incentive Program, an eligible professional 

is required to meet certain objectives and associated measures in order to achieve meaningful 

use. One of these objectives is for the eligible professional to generate and transmit permissible 

prescriptions electronically, and the measure of whether the eligible professional has met this 

objective is more than 40 percent of all permissible prescriptions written by the eligible 

professional are transmitted electronically using Certified EHR Technology (§495.6(d)(4)). We 

note that the EHR Incentive Program and the eRx Incentive Program share a common goal of 

encouraging electronic prescribing and the adoption of technology that enables eligible 

professionals to electronically prescribe. This goal is advanced under each program via the 

respective program requirements – the electronic prescribing objective under the EHR Incentive 

Program and the requirement that an EP be a “successful electronic prescriber” under the eRx 

Incentive Program. Indeed, both programs require that the eligible professionals indicate their 

electronic prescribing activity. Under the EHR Incentive Program, an eligible professional must 

attest to the percentage of his or her permissible prescriptions that were generated and 

transmitted electronically using Certified EHR Technology during the applicable EHR reporting 

period, which must exceed 40 percent. Under the eRx Incentive Program, to avoid the payment 
CMS-1590-P 534 

adjustment, eligible professional must be a successful electronic prescriber, which is achieved by 

the reporting of the eRx quality measure a certain number of instances during the applicable 

reporting period (each instance of reporting of the eRx quality, which includes reporting of 

specific quality data codes, signifies that the professional generated an electronic prescription for 

a specified service or encounter). In most cases, we believe the electronic prescribing objective 

of meaningful use would be a more rigorous standard for eligible professionals to meet than the 

standard adopted under the eRx Incentive Program (as demonstrated via the reporting of the eRx 

quality measure). In addition, there seems to be no added benefit with regard to reporting 

(presumably lower) electronic prescribing activity under the eRx Incentive Program given that 

the identical goals (encouraging electronic prescribing) of both programs would have been 

fulfilled through the eligible professional’s achievement of meaningful use. For those reasons, 

we believe it may pose a significant hardship for eligible professionals who are meaningful EHR 

users to additionally comply with the requirements of being a successful electronic prescriber 

under the eRx Incentive program. 

For the reasons stated, under this proposed significant hardship category, we propose that 

individual eligible professionals (and every eligible professional member of a group practice

group practice practices for the 2014 payment adjustment only) would need to achieve meaningful use 

of Certified EHR Technology for a continuous 90-day EHR reporting period (as defined for the 

EHR Incentive Program) that falls within the 6-month reporting period (January 1 - June 30, 

2012) for the 2013 eRx payment adjustment or the 12- or 6-month reporting periods (January 1- 

December 31, 2012 or January1 – June 30, 2013, respectively) for the 2014 eRx payment 

adjustment to be eligible to request a significant hardship exemption. We also propose that for 

purposes of the 2013 and 2014 eRx payment adjustments this hardship exemption category 

would apply to individual EPs and group practices (that is, every member of the group) who 
CMS-1590-P 535 

instead achieve meaningful use of Certified EHR Technology for an EHR reporting period that is 

the full CY 2012. In section III.H.5.b. below, we discuss the proposed deadlines and procedures 

for requesting consideration of an exemption under this proposed significant hardship exemption 

category. 

B. Eligible professionals or group practices who demonstrate intent to participate in the EHR 

Incentive Program and adoption of Certified EHR Technology 

 We note that we finalized at §414.92(c)(2)(ii)(A)(3) a significant hardship exemption 

category for the 2012 eRx payment adjustment, under which eligible professionals and group 

practices seeking consideration for an exemption were required to register to participate in the 

EHR Incentive Program and adopt CEHRT (76 FR 54958). That significant hardship category 

addressed significant hardships relating to the selection, purchase and adoption of eRx 

technology (for example, potential significant financial hardship of purchasing two sets of eRx 

equipment for both programs) that may have occurred as a result of the timing of the release of 

the standards and requirements for CEHRT and the Certified Health IT Product List, the 

establishment of the respective program requirements for the eRx and EHR Incentive Programs, 

and the 2012 eRx payment adjustment reporting periods. Given that eligible professionals have 

had adequate time to identify EHR products that have been certified and that the requirements 

for these programs have been implemented and, various stages of reporting are underway, we do 

not believe this significant hardship exemption category would continue to be applicable for the 

2013 and 2014 eRx payment adjustments. We understand, however, that although an eligible 

professional may now have the requisite information about requirements for CEHRT and each 

respective program, there may nevertheless exist a significant hardship with regard to 

compliance with the requirements for being a successful electronic prescriber under the eRx 
CMS-1590-P 536 

Incentive Program, given the nature of CEHRT and how it is used/implemented in one’s 

practice. 

When an eligible professional or eligible professional in a group practice first adopts 

CEHRT, we understand significant changes may be required with regard to how the eligible 

professional’s practice operates. Further, necessary steps are involved in fully implementing 

CEHRT once it has been adopted, including: installation, configuration, customization, training, 

workflow redesign and the establishment of connectivity with entities that facilitate electronic 

health information exchange (such as for electronic prescriptions). Thus, we believe it would be 

difficult for an eligible professional or eligible professional in a group practice who has adopted 

CEHRT to be able to begin electronically prescribing on day one. Rather, we expect a natural 

lag time would likely occur between an eligible professional’s adoption of CEHRT and the point 

at which CEHRT has been fully implemented such that an eligible professional could begin 

electronically prescribing. We believe this implementation timeline may pose a significant 

hardship for an eligible professional or group practice who seeks to comply with the 

requirements for being a successful electronic prescriber under the eRx Incentive Program and 

also participate for the first time in the EHR Incentive Program. Under the EHR Incentive 

Program, an eligible professional who is demonstrating meaningful use of CEHRT for the first 

time must do so for any continuous 90-day period within the calendar year (the “EHR reporting 

period”). In the absence of this significant hardship exemption category, eligible professionals 

or group practices who choose a 90-day EHR reporting period that falls later in the year may 

potentially have to adopt two systems (for example, a stand-alone electronic prescribing system 

for purposes of participating in the eRx Incentive Program, and CEHRT for purposes of 

participating in the EHR Incentive Program), which could be financially burdensome. 

Alternatively, such eligible professionals who wish to use CEHRT for purposes of participating 
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in both programs may potentially have to adopt and implement CEHRT well in advance of their 

90-day EHR reporting period in order to meet an earlier reporting period for the eRx Incentive 

Program. 

Therefore, for the 2013 and 2014 eRx payment adjustments, we are proposing a 

significant hardship exemption category to address this situation. We believe, however, that for 

this category it is necessary for eligible professionals and group practices to show they intend to 

participate in the EHR Incentive Program for the first time and have adopted CEHRT. 

Therefore, to be eligible for consideration for an exemption under this proposed significant 

hardship exemption category for the 2013 and 2014 eRx payment adjustments, we propose that 

eligible professionals or group practices must register to participate in the Medicare or Medicaid 

EHR Incentive Programs and adopt CEHRT by a date specified by CMS. We further note that, 

given the nature of the significant hardship at issue under this category, this proposal would be 

limited to eligible professionals and group practices (that is, every individual EP member of the 

group practice): (1) who have not previously adopted CEHRT or received an incentive payment 

under the Medicare or Medicaid EHR Incentive Programs; and (2) who attempt to participate in 

the Medicare or Medicaid EHR Incentive Programs from January 2, 2012 through October 15, 

2012, or the effective date of the final rule (which includes the 6-month 2013 eRx payment 

adjustment reporting period of January 1, 2012-June 30, 2012) for the 2013 eRx payment 

adjustment, or during the 6 month payment adjustment reporting period for the 2014 eRx 

payment adjustment (January 1, 2013 through June 30, 2013). 

With respect to eligible professionals or group practiceswho intend to adopt EHR 

technology in the future or have not yet taken the steps required in order to apply for this 

significant hardship exemption, we believe that mere intent to adopt CEHRT or attest at a later 

date does not sufficiently demonstrate that an eligible professional will adopt CEHRT to 
CMS-1590-P 538 

participate in the Medicare or Medicaid EHR Incentive Programs. Unlike those eligible 

professionals who would have registered for the Medicare or Medicaid EHR Incentive Programs 

and have adopted CEHRT available for immediate use, we would have to monitor and provide 

oversight over those eligible professionals who have not yet taken these steps to participate in the 

Medicare or Medicaid EHR Incentive Programs. We also do not believe that such eligible 

professionals or group practices would necessarily be facing a significant hardship as 

contemplated in this proposed exemption category. Accordingly, all of the proposed 

requirements to qualify for an exemption under this significant hardship exemption category 

would need to be met by the time the eligible professional requests an exemption. In section 

III.H.5.b. below, we discuss the proposed deadlines and procedures for requesting consideration 

of an exemption under this proposed significant hardship exemption category. We invite public 

comment on these two proposed significant hardship exemption categories for the 2013 and 2014 

payment adjustments.

C. Proposed Deadlines and Procedures for Requesting Significant Hardship Exemptions

 In the CY 2012 final rule with comment period, we established a process whereby 

eligible professionals would submit significant hardship exemptions for the existing significant 

hardship exemption categories for the eRx payment adjustments (76 FR 54963). Unfortunately, 

with respect to submitting these proposed significant hardship exemptions for the 2013 eRx 

payment adjustment, it would not be operationally feasible to accept significant hardship 

exemption requests in the manner we previously established. Therefore, we propose that, in 

order to request a significant hardship under the two proposed significant hardship exemption 

categories for the 2013 eRx payment adjustment, CMS would analyze the information provided 

to us in the Registration and Attestation System under the EHR Incentive Program to determine 

whether the eligible professional or group practice (that is, every EP member of the group 
CMS-1590-P 539 

practice) has either (1) achieved meaningful use under the EHR Incentive Program during the 

applicable reporting periods we noted previously, or (2) registered to participate in the EHR 

Incentive Program via the Registration and Attestation system for the EHR Incentive Program 

(located at https://ehrincentives.cms.gov/hitech/login.action) and adopted CEHRT, or both, if 

applicable. We understand that providing an eligible professionals CEHRT product number is an 

optional field in the Registration Page. Please note that if requesting a significant hardship 

exemption under proposed category 2, the eligible professional must provide its CEHRT product 

number when registering for the EHR Incentive Program. In the event that it is not operationally 

feasible to accept this information via the Registration and Attestation system for the EHR 

Incentive Program, we propose that we would accept requests for significant hardship 

exemptions under these two proposed categories via a mailed letter to CMS to the following 

address: Centers for Medicare & Medicaid Services, Office of Clinical Standards and Quality, 

Quality Measurement and Health Assessment Group, 7500 Security Boulevard, Mail Stop S3-

02-01, Baltimore, MD 21244-1850. 

 Regardless of which method is finalized for the 2013 eRx payment adjustment, we 

propose that eligible professionals would be required to submit this significant hardship requests 

by October 15, 2012 or the effective date of the final rule for this provision, whichever is later. 

For those eligible professionals who request a significant hardship exemption based on achieving 

meaningful use under the EHR Incentive Program during the 12- or 6-month reporting periods 

for the 2013 payment adjustment, we also propose that the eligible professional would be 

required to have attested under the EHR Incentive Program by October 15th of 2012 (or if later, 

the effective date of the final rule), in order to qualify for a significant hardship exemption for 

the 2013 payment adjustment. For those eligible professionals requesting a significant hardship 

exemption for the 2013 eRx payment adjustment under the second proposed significant hardship 
CMS-1590-P 540 

exemption category (that is, intent to participate in the EHR Incentive Program and adoption of 

CEHRT), we propose that these eligible professionals who intend to participate in the EHR 

Incentive Program from January 1, 2011 through October 15, 2012 or the effective date of the 

final rule would be required to register for the EHR Incentive Program and adopt CEHRT by the 

same deadline noted above, in order to qualify for a significant hardship exemption for the 2013 

eRx payment adjustment. 

 We note that we are proposing a later deadline of October 15, 2012 (or the effective date 

of the final rule, if later) for the submission of these requests because the deadline for submitting 

requests under other previously established significant hardship exemption categories to the 2013 

eRx payment adjustment (June 30, 2012) has passed and other similar dates we might choose 

would likely have passed by the time the final rule is effective. We note that this October 15, 

2012 deadline is consistent with our intent to finalize our proposals related to these two 

additional significant hardship exemptions in early Fall 2012, prior to the publication of the CY 

2013 Medicare PFS final rule. However, to the extent we are not able to finalize these proposals 

in the Fall 2012, please note that we may finalize the provisions related to the two proposed 

significant hardship exemption categories in the CY 2013 Medicare PFS final rule. If such is 

the case, we propose to extend the October 15, 2012 deadline to the effective date of the CY 

2013 Medicare PFS final rule. 

 In addition, we would like to be able to process all such requests before we begin making 

the claims processing systems changes later this year to adjust eligible professionals’ or group 

practices’ payments starting on January 1, 2013. However, we anticipate that, in some cases, 

particularly in instances where eligible professionals submit significant hardship exemption 

requests closer towards the deadline, we may not be able to complete our review of the requests 

before the claims processing systems updates are made to begin reducing eligible professionals’ 
CMS-1590-P 541 

and group practices’ PFS amounts in 2013. In such cases, if we ultimately approve the eligible 

professional or group practice’s request for a significant hardship exemption after January 1, 

2013, we would need to reprocess all claims for services furnished up to that point in 2013 that 

were paid at the reduced PFS amount, which we anticipate may take several months. In order to 

avoid the reprocessing of claims, we encourage eligible professionals who would be submitting a 

significant hardship exemption request under these two categories to do so as soon as possible, 

rather than waiting until the deadline to submit such a request. 

 We note that we are only proposing submission of requests for significant hardship 

exemptions under these 2 categories under an individual eligible professional level only because 

it is not technically feasible for us to operationally analyze information on the EHR Incentive 

Program’s Registration and Attestation page using the TIN, as the information stored in this 

system is stored by NPI. However, we seek not to preclude eligible professionals currently in an 

eRx GPRO for 2012 from submitting requests for significant hardship exemptions under these 2 

proposed categories. Therefore, to allow the submission of significant hardship requests for the 

2013 eRx payment adjustment under these 2 proposed categories, we propose that eligible 

professionals within an eRx GPRO may, as individuals, request a significant hardship exemption 

under these 2 proposed categories. Please note, however, that if an entire eRx GPRO wishes to 

request a significant hardship exemption under these 2 proposed categories, then each eligible 

professional in the group practice must submit a request. 

 With respect to submitting exemption requests for the 2 proposed significant hardship 

exemption categories for the 2014 eRx payment adjustment, we propose the following method 

for submitting a request for a significant hardship exemption: Via the Communication Support 

Page (which is the method established for submitting the established significant hardship 

exemption categories). 
CMS-1590-P 542 

 In addition, we considered accepting significant hardship exemption requests for the 2 

proposed significant hardship exemption categories for the 2014 eRx payment adjustment by 

CMS receiving eligible professional’s information through the Registration and Attestation 

System for the EHR Incentive Program (similar to our proposed submission process for the 2013 

eRx payment adjustment) and via a mailed letter to CMS using the following address: Centers 

for Medicare & Medicaid Services, Office of Clinical Standards and Quality, Quality 

Measurement and Health Assessment Group, 7500 Security Boulevard, Mail Stop S3-02-01, 

Baltimore, MD 21244-1850. We invite public comment on these considered submission options. 

 We propose that the deadline for submitting these significant hardship exemption 

requests for the 2014 eRx payment adjustment would be June 30, 2013, which is the same 

deadline established for submitting a significant hardship exemption request for the existing 

significant hardship exemption categories. Additionally, and consistent with our proposal for the 

2013 eRx payment adjustment, we propose that an eligible professional or group practice (that is, 

all members of the practice) that achieves meaningful use under the EHR Incentive Program 

during the 6- or 12-month reporting periods for the 2014 eRx payment adjustment would be 

required to attest by June 30, 2013. Similarly, for eligible professionals requesting a significant 

hardship exemption for the 2014 eRx payment adjustment under the second proposed significant 

hardship exemption category (i.e., intent to participate in the EHR Incentive Program and 

adoption of CEHRT), we propose that these eligible professionals who intend to participate in 

the EHR Incentive Program during the last six months of 2013 would be required to register for 

the EHR Incentive Program and adopt CEHRT by June 30, 2013, in order to qualify for a 

significant hardship exemption for the 2014 eRx payment adjustment. We understand that these 

deadlines may exclude some eligible professionals who attest or register for the EHR Incentive 

Program at later dates, but these deadlines are necessary in order to avoid the reprocessing of 
CMS-1590-P 543 

claims. We note, however, that these proposed deadlines would not extend any deadlines 

applicable under the EHR Incentive Program. That is, for purposes of the EHR Incentive 

Program, an eligible professional must still attest to being a meaningful user by the deadline 

established under the EHR Incentive Program, even if such deadline falls prior to the proposed 

eRx Incentive program significant hardship exemption deadline. We invite public comment on 

this proposed process for submitting requests significant hardship exemptions under these two 

proposed categories. 

6. Informal Review 

 To better facilitate issues surrounding the issuance of incentives and payment 

adjustments, we propose to establish an informal review process for the eRx Incentive Program. 

We are proposing an informal review process similar to the informal review process established 

for the PQRS (76 FR 73390), because eligible professionals and group practices are already 

familiar with this process. The proposed informal review process, which is described below, 

would only be available for the 2013 eRx incentive payments and the 2014 eRx payment 

adjustment. 

 For an informal review regarding the 2013 incentive, we propose that an eligible 

professional or group practice must request an informal review within 90 days of the release of 

his or her feedback report, irrespective of when an eligible professional or group practice 

actually accesses his/her feedback report. 

 For an informal review regarding the 2014 payment adjustment, we propose that an 

eligible professional or group practice must request an informal review by January 31, 2013. We 

believe this deadline provides ample time for eligible professionals and group practices to 

discover that their respective claims are being adjusted due to the 2014 payment adjustment and 

seek informal review. 
CMS-1590-P 544 

 We propose that the request must be submitted in writing and summarize the concern(s) 

and reasons for requesting an informal review. In its request for an informal review, eligible 

professional may also submit other information to assist in the review. 

We propose that an eligible professional may request an informal review through the web. We 

believe use of the web would provide a more efficient way for CMS to record informal review 

requests, as the web would guide the eligible professional through the creation of an informal 

review requests. For example, the web-based tool would prompt an eligible professional of any 

necessary information he or she must provide. Should it be technically not feasible to receive 

requests for informal reviews via the web, we propose that as eligible professional would be able 

to request an informal review via email. 

 We further propose that we would make our determination and provide the eligible 

professional or group practice with a written response to his or her request for an informal review 

within 90 days of receiving the request. 

 Based on our informal review and once we have made a determination, we propose that 

we would provide the eligible professional or group practice a written response. Where we find 

that the eligible professional or group practice did successfully report for the 2013 incentive, we 

would provide the eligible professional or group practice with the applicable incentive payment. 

Where we find that the eligible professional or group practice did successfully report (that is, 

meet criteria for being a successful electronic prescriber) for purposes of the 2014 payment 

adjustment, we would cease application of the 2014 payment adjustment and reprocess all claims 

that have been adjusted.We further propose that decisions based on the informal review would be 

final, and there would be no further review or appeal. 

 We invite public comment on our proposals for the eRx Incentive Program informal 

review process for the 2013 incentive and the 2014 payment adjustment. 
CMS-1590-P 545 

a. Proposed Criteria for the PQRS-Medicare EHR Incentive Pilot 

 The Medicare EHR Incentive Program provides incentive payments to eligible 

professionals (EPs) who demonstrate meaningful use of certified EHR technology (CEHRT). 

EPs who fail to demonstrate meaningful use will be subject to payment adjustments beginning in 

2015. We established a phased approach to meaningful use, which we expect will include three 

stages (75 FR 44321), and all EPs are currently in Stage 1. In the CY 2012 Medicare PFS final 

rule, we established the PQRS-Medicare EHR Incentive Pilot in an effort to pilot the electronic 

submission of CQMs for the Medicare EHR Incentive Program and move towards the alignment 

of quality reporting requirements between Stage 1 of the Medicare EHR Incentive Program and 

the PQRS (76 FR 73422). We refer readers to the final rule for further explanation of the 

requirements of the Pilot (76 FR 73422 – 73425). Specifically, we established that an EP 

participating in the PQRS-Medicare EHR Incentive Pilot would be able to report clinical quality 

measures (CQMs) data extracted from Certified EHR Technology via use of a PQRS qualified 

direct EHR product or PQRS qualified EHR data submission vendor product (76 FR 73422). We 

propose to modify §495.8 to extend this Pilot for the 2013 payment year as it was finalized for 

the 2012 payment year. We are also proposing to remove from §495.8(a)(2)(v) the crossreference to §495.6(d)(10) in order to conform with the proposed changes to §495.6(d) that were 

included in the EHR Incentive Program – Stage 2 NPRM (77 FR 13698, 13702). This proposal 

includes the following: 

● For the 2013 payment year only, EPs intending to participate in the PQRS-Medicare 

EHR Incentive Pilot may use a PQRS qualified EHR data submission vendor product that would 

submit CQM data extracted from the EP’s CEHRT to CMS. Under this option, identical to the 

submission process used for the Pilot in 2012 for the 2012 payment year, the PQRS qualified 

EHR data submission vendor would calculate the CQMs from the EP’s CEHRT and then submit 
CMS-1590-P 546 

the calculated results to CMS on the EP’s behalf via a secure portal for purposes of this Pilot. 

● For the 2013 payment year only, identical to the submission process used for the Pilot 

in 2012 for the 2012 payment year, EPs intending to participate in the PQRS-Medicare EHR 

Incentive Pilot may use a PQRS qualified direct EHR product to submit CQM data directly from 

his or her CEHRT to CMS via a secure portal using the infrastructure of the PQRS EHR-based 

reporting mechanism. 

In addition, for the 2013 payment year, we are proposing to extend the use of attestation 

as a reporting method for the CQM component of meaningful use for the EHR Incentive 

Program. For 2013, EPs would be able to continue to report by attestation CQM results as 

calculated by CEHRT, as they did for 2011 and 2012. We refer readers to the EHR Incentive 

Program – Stage 1 final rule for further explanation of the CQM reporting criteria for EPs and 

attestation (75 FR 44386 – 44411, 44430 – 44434). 

 We invite public comment on our proposal to extend the PQRS-Medicare EHR Incentive 

Pilot and attestation as it was established for the 2012 payment year to the 2013 payment year. 

Please note that we are only proposing the extension of the PQRS-Medicare EHR Incentive Pilot 

to the 2013 payment year, because Stage 2 of the EHR Incentive Program is expected to begin in 

2014. The proposals for Stage 2 of the EHR Incentive Program were provided in a standalone 

proposed rule published on March 7, 2012 (77 FR 13698).

I. Medicare Shared Savings Program

1. Medicare Shared Savings Program and Physician Quality Reporting System Payment 

Adjustment 

 Under section 1899 of the Act, CMS has established a 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 
CMS-1590-P 547 

growth in healthcare costs. Eligible groups of providers and suppliers, including physicians, 

hospitals, and other healthcare 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 Federal Register on November 2, 

2011 (Medicare Shared Savings Program: Accountable Care Organizations Final Rule (76 FR 

67802)). 

 Section 1899(b)(3)(D) of the Act affords the Secretary discretion to “* * * incorporate 

reporting requirements and incentive payments related to the physician quality reporting 

initiative (PQRI), under section 1848 of the Act, including such requirements and such payments 

related to electronic prescribing, electronic health records, and other similar initiatives under 

section 1848 * * *” and permits the Secretary to “use alternative criteria than would otherwise 

apply [under section 1848 of the Act] for determining whether to make such payments.” Under 

this authority, we incorporated certain Physician Quality Reporting System (PQRS) reporting 

requirements and incentive payments into the Shared Savings Program (76 FR 67902). In the 

Shared Savings Program final rule, we finalized the following requirements with regard to PQRS 

incentive payments under the Shared Savings Program: (1) the 22 GPRO quality measures 

identified in Table 1 of the final rule (76 FR 67889-67890); (2) reporting via the GPRO web 

interface (76 FR 67893); (3) criteria for satisfactory reporting (76 FR 67900); and (4) January 1 

through December 31 as the reporting period. The regulation governing the incorporation of 

PQRS incentives and reporting requirements under the Shared Savings Program is set forth at 

§425.504. 

Under § 425.504(a)(1), ACOs, on behalf of their ACO provider/suppliers who are 

eligible professionals, must submit the measures determined under § 425.500 using the GPRO 

web interface established by CMS, to qualify on behalf of their eligible professionals for the 
CMS-1590-P 548 

PQRS incentive under the Shared Savings Program. ACO providers/suppliers that are eligible 

professionals constitute a group practice for purposes of qualifying for a PQRS incentive under 

the Shared Savings Program. Under §425.504(a)(2)(ii), an ACO, on behalf of its ACO 

providers/suppliers who are eligible professionals, must satisfactorily report the measures 

determined under the Shared Savings Program during the reporting period according to the 

method of submission established by CMS in order to receive a PQRS incentive under the 

Shared Savings Program. For the years in which a PQRS incentive is available, if eligible 

professionals that participate in an ACO as ACO providers/suppliers qualify for a PQRS 

incentive payment under the Medicare Shared Savings Program, the ACO participant TIN(s) 

under which those ACO providers/suppliers bill, will receive an incentive payment based on the 

allowed charges of those ACO providers/suppliers. Under §425.504(a)(4) , ACO participant 

TINs and individual ACO providers/suppliers who are eligible professionals cannot earn a PQRS 

incentive outside of the Medicare Shared Savings Program. The PQRS incentive under the 

Medicare Shared Savings Program is equal to 0.5 percent of the Secretary’s estimate of the 

ACO’s eligible professionals’ total Medicare Part B PFS allowed charges for covered 

professional services furnished during the calendar year reporting period from January 1 through 

December 31, for years 2012 through 2014. 

As discussed in section III.G of this proposed rule, as required by section 1848(a)(8) of 

the Act , a payment adjustment will apply under the PQRS beginning in 2015. For eligible 

professionals who are not satisfactory reporters, the PFS amount for covered professional 

services furnished by the eligible professional during 2015 shall be equal to 98.5 percent (and 98 

percent for 2016 and each subsequent year) of the fee schedule amount that would otherwise 

apply to such services. Therefore, consistent with our authority under section 1899(b)(3)(D) of 

the Act, we propose to amend §425.504 to incorporate reporting requirements for the PQRS 
CMS-1590-P 549 

payment adjustment under the Shared Savings Program for eligible professionals that are ACO 

providers/suppliers. 

 We are proposing to incorporate requirements for the PQRS payment adjustment that are 

consistent with requirements for PQRS incentives that we previously adopted in the Shared 

Savings Program final rule. Specifically, for purposes of the PQRS payment adjustment, we 

propose to incorporate the same PQRS GPRO under the Shared Savings Program that is 

currently used for purposes of the PQRS incentive under the Shared Savings Program. Under 

this proposal, eligible professionals that are ACO providers/suppliers would constitute a group 

practice that would report quality measures via the GPRO data collection tool for purposes of 

both the PQRS incentive under the Shared Savings Program and the PQRS payment adjustment 

under the Shared Savings Program. 

For purposes of the payment adjustment, we propose to use the final GPRO quality 

measures adopted under the Shared Shavings Program that appear in Table 1 of the Shared 

Savings Program final rule (76 FR 67899-67890). We further propose to incorporate the same 

criteria for satisfactory reporting that were finalized for the PQRS incentive under the Shared 

Savings Program, which are described in the Shared Savings Program final rule (76 FR 67900). 

Specifically: 

• An ACO on behalf of its eligible professionals must report on all measures 

included in the GPRO data collection tool under the Shared Savings Program final 

rule. 

• Beneficiaries would be assigned to the ACO using the methodology described in 

§ 425.400. As a result, the GPRO tool would be populated based on a sample of 

the ACO-assigned beneficiary population. ACOs must to complete the tool for 

the first 411 consecutively ranked and assigned beneficiaries in the order in which 
CMS-1590-P 550 

they appear in the group’s sample for each domain, measures set, or individual 

measure if a separate denominator is required such as in the case of preventive 

care measures which may be specific to one sex. If the pool of eligible assigned 

beneficiaries is less than 411, the ACO must report on 100 percent of assigned 

beneficiaries for the domain, measures set, or individual measure. 

• The GPRO data collection tool must be completed for all domains, measure sets 

and measures described in Table 1 of the of the Shared Savings Program final rule 

(76 FR 67889-67890). 

Consistent with the reporting requirements for the PQRS incentive under the Shared Savings 

Program, ACOs would only need to satisfactorily report the 22 GPRO quality measures 

identified in Table 1 of the Shared Savings Program final rule (76 FR 67889-67890), and would 

not need to report the other 11 Shared Savings Program quality performance measures for 

purposes of satisfactory reporting for the PQRS payment adjustment. However, the ACO would 

still be required to satisfy the ACO quality performance standards for purposes of determining 

eligibility for shared savings, as described in §425.502. 

We believe that using the same quality measures and the same criteria for satisfactory 

reporting, including the same assignment and sampling methodology, under the Shared Savings 

program for both the PQRS incentive and payment adjustment is appropriate. Aligning the 

satisfactory reporting requirements for the PQRS payment adjustment under the Shared Savings 

Program with the reporting requirements for purposes of the PQRS incentive under the Shared 

Savings Program would enable eligible professionals that participate in ACOs as ACO 

providers/suppliers to comply with these reporting requirements, without imposing any 

additional reporting burden. In addition, as noted above, the 22 GPRO measures that are 

reported for purposes of the PQRS incentive under the Shared Savings Program must also be 
CMS-1590-P 551 

reported for purposes of assessing ACOs’ quality performance under the Shared Savings 

Program and determining the percentage of shared savings that ACOs are eligible to receive. 

Under the Shared Savings Program regulations at §425.500(e)(3), ACOs are required to report 

on all of the quality measures established by CMS, and the failure to report on those quality 

measures accurately, completely, and timely may subject the ACO to termination or other 

sanctions. Thus, ACOs already have significant incentives to report the 22 GPRO measures 

completely and accurately. Furthermore, aligning the reporting requirements could help to 

encourage greater participation in the Shared Savings Program, by minimizing the reporting 

burden imposed upon ACOs and their participants. 

Although we propose to use the same timeframe of January 1 through December 31 that 

we adopted for the PQRS incentive under the Shared Savings Program as the reporting period for 

the PQRS payment adjustment, we propose that the timing of the reporting period would differ 

for purposes of the PQRS payment adjustment. Specifically, we propose that the reporting 

period for the payment adjustment would fall 2 years prior to when the payment adjustment 

would be assessed. For example, under the Shared Savings Program, the reporting period for the 

2015 payment adjustment would be from January 1, 2013 through December 31, 2013. It is 

necessary for us to use a reporting period that precedes the year in which the payment adjustment 

is applicable to avoid retroactive payments and the reprocessing of claims. In addition, it is not 

operationally feasible for us to use a full calendar year reporting period that falls closer to the 

year in which the payment adjustment is applicable because we need sufficient time to determine 

if the requirements for satisfactory reporting have been met and to adjust our claims systems 

prior to the start of the applicable year. We note that the length and timing of the reporting 

period that we are proposing for the PQRS payment adjustment under the Shared Savings 

Program is consistent with the one used for the traditional PQRS (76 FR 73392). 
CMS-1590-P 552 

We also note that this proposal results in overlapping reporting periods for both the 

PQRS incentive and payment adjustment. For example, the measure data collected for the 2013 

calendar year reporting period (January 1, 2013-December 31, 2013) would be used for purposes 

of both the Physician Quality Reporting System 2013 incentive and 2015 payment adjustment 

under the Shared Savings Program. We believe using the same reporting period for purposes of 

both the incentive and payment adjustment would result in less reporting burden, since one set of 

measures from one reporting period would be used for purposes of both the PQRS incentive and 

payment adjustment. We believe ACOs will perceive this as more efficient than requiring one set 

of measures reported during one timeframe for purposes of the PQRS incentive and another set 

during another timeframe for purposes of the payment adjustment. 

 Therefore, we propose that, if an ACO satisfactorily reports the ACO GPRO web 

interface measures during the applicable reporting period, its participant TINs with ACO 

providers/suppliers who are eligible professionals, would not be subject to the PQRS payment 

adjustment. If an ACO does not satisfactorily report the ACO GPRO web interface measures 

during the applicable reporting period, its participant TINs with ACO providers/suppliers who 

are eligible professionals, would be subject to the PQRS payment adjustment starting in 2015. 

 Since the publication of the Shared Savings Program final rule, we have received a 

number of inquiries regarding whether ACO participant TINs need to self-nominate or register to 

participate in PQRS GPRO under the Shared Savings Program, since there are such registration 

and self-nomination requirements under the traditional PQRS GPRO. We wish to clarify that no 

registration or self-nomination is required for ACO providers/suppliers that are eligible 

professionals to participate in PQRS under the Shared Savings Program. 

Finally, just as ACO providers/suppliers that are eligible professionals with an ACO may 

only participate under their ACO participant TIN as a group practice under the PQRS GPRO 
CMS-1590-P 553 

under the Shared Savings Program for purposes of receiving an incentive as both a group and as 

an individual under the same TIN (76 FR 67903), we propose that ACO providers/suppliers that 

are eligible professionals within an ACO must participate under the ACO participant TIN as a 

group practice under the PQRS GPRO under the Shared Savings Program for purposes of the 

PQRS payment adjustment. Thus, ACO providers/suppliers who are eligible professionals may 

not seek to avoid the payment adjustment by reporting either as an individual under the 

traditional PQRS or under the traditional PQRS GPRO. 

We recognize that some eligible professionals may move across programs and reporting 

options from year to year. For instance, an eligible professional that is an ACO provider/supplier 

and participates in the PQRS under the Shared Savings Program in 2013 may later exit the 

Shared Savings Program and participate in PQRS individual reporting in 2014. Alternatively, a 

group practice participating in the traditional PQRS GPRO in 2013 may be an ACO participant 

in 2014. In instances in which eligible professionals change their PQRS reporting option from 

year to year, we believe that as long as the eligible professional satisfactorily reported for 

purposes of the payment adjustment during the applicable reporting period, then the eligible 

professional should not be subject to the payment adjustment even if the eligible professional 

was reporting under a different reporting method than at the time the payment adjustment would 

be assessed. Using the earlier example, if an eligible professional is an ACO provider/supplier 

and satisfactorily reports under the PQRS under the Shared Savings Program in 2013 but 

subsequently exits the Shared Savings Program and participates in PQRS individual reporting in 

2014, the eligible professional would not be subject to the payment adjustment in 2015. 

Similarly, a group practice that satisfactorily reports under the traditional PQRS GPRO in 2013 

and becomes an ACO participant in 2014 would not be subject to the payment adjustment in 

2015. We recognize that group practices and ACOs may reorganize and that individual providers 
CMS-1590-P 554 

and groups of providers may move in and out of ACOs from year to year, so we believe this 

approach offers maximum flexibility for eligible professionals and groups of providers to make 

appropriate decisions regarding their participation in an ACO and allows ACOs to recruit new 

participants, by eliminating any risk that eligible professionals will be assessed with the payment 

adjustment as a result of such changes. We believe it would be unfair to assess the payment 

adjustment on an eligible professional on the basis of switching reporting options, if the eligible 

professional had satisfactorily reported during the applicable reporting period. We invite public 

comment on our proposals for Shared Savings Program ACOs and the PQRS payment 

adjustment and on the alternative considered. 

Please note that, in this proposed rule, we also discuss a proposal amending requirements 

for ACO data to be publicly reported on Physician Compare in section III.G. of this proposed 

rule. 
CMS-1590-P 555 

J. Discussion of Budget Neutrality for the Chiropractic Services Demonstration

Section 651 of MMA requires the Secretary to conduct a demonstration for up to 2 years 

to evaluate the feasibility and advisability of expanding coverage for chiropractic services under 

Medicare. Current Medicare coverage for chiropractic services is limited to treatment by means 

of manual manipulation of the spine to correct a subluxation described in section 1861(r)(5) of 

the Act provided such treatment is legal in the State or jurisdiction where performed. The 

demonstration expanded Medicare coverage to include: “(A) care for neuromusculoskeletal 

conditions typical among eligible beneficiaries; and (B) diagnostic and other services that a 

chiropractor is legally authorized to perform by the State or jurisdiction in which such treatment 

is provided.” The demonstration was conducted in four geographically diverse sites, two rural 

and two urban regions, with each type including a Health Professional Shortage Area (HPSA). 

The two urban sites were 26 counties in Illinois and Scott County, Iowa, and 17 counties in 

Virginia. The two rural sites were the States of Maine and New Mexico. The demonstration, 

which ended on March 31, 2007, was required to be budget neutral as section 651(f)(1)(B) of 

MMA mandates the Secretary to ensure that “the aggregate payments made by the Secretary 

under the Medicare program do not exceed the amount which the Secretary would have paid 

under the Medicare program if the demonstration projects under this section were not 

implemented.” 

In the CY 2006, 2007, and 2008 PFS final rules with comment period (70 FR 70266, 

71 FR 69707, 72 FR 66325, respectively), we included a discussion of the strategy that would be 

used to assess budget neutrality (BN) and the method for adjusting chiropractor fees in the event 

the demonstration resulted in costs higher than those that would occur in the absence of the 

demonstration. We stated that BN would be assessed by determining the change in costs based 

on a pre-post comparison of total Medicare costs for beneficiaries in the demonstration and their 
CMS-1590-P 556 

counterparts in the control groups and the rate of change for specific diagnoses that are treated by 

chiropractors and physicians in the demonstration sites and control sites. We also stated that our 

analysis would not be limited to only review of chiropractor claims because the costs of the 

expanded chiropractor services may have an impact on other Medicare costs for other services. 

In the CY 2010 PFS final rule with comment period (74 FR 61926), we discussed the 

evaluation of this demonstration conducted by Brandeis University and the two sets of analyses 

used to evaluate BN. In the “All Neuromusculoskeletal Analysis,” which compared the total 

Medicare costs of all beneficiaries who received services for a neuromusculoskeletal condition in 

the demonstration areas with those of beneficiaries with similar characteristics from similar 

geographic areas that did not participate in the demonstration, the total effect of the 

demonstration on Medicare spending was $114 million higher costs for beneficiaries in areas that 

participated in the demonstration. In the “Chiropractic User Analysis,” which compared the 

Medicare costs of beneficiaries who used expanded chiropractic services to treat a 

neuromusculoskeletal condition in the demonstration areas, with those of beneficiaries with 

similar characteristics who used chiropractic services as was currently covered by Medicare to 

treat a neuromusculoskeletal condition from similar geographic areas that did not participate in 

the demonstration, the total effect of the demonstration on Medicare spending was a $50 million 

increase in costs. 

As explained in the CY 2010 PFS final rule, we based the BN estimate on the 

“Chiropractic User Analysis” because of its focus on users of chiropractic services rather than all 

Medicare beneficiaries with neuromusculoskeletal conditions, as the latter included those who 

did not use chiropractic services and who may not have become users of chiropractic services 

even with expanded coverage for them (74 FR 61926 through 61927). Users of chiropractic 

services are most likely to have been affected by the expanded coverage provided by this 
CMS-1590-P 557 

demonstration. Cost increases and offsets, such as reductions in hospitalizations or other types 

of ambulatory care, are more likely to be observed in this group. 

As explained in the CY 2010 PFS final rule (74 FR 61927), because the costs of this 

demonstration were higher than expected and we did not anticipate a reduction to the PFS of 

greater than 2 percent per year, we finalized a policy to recoup $50 million in expenditures from 

this demonstration over a 5-year period, from CYs 2010 through 2014 (74 FR 61927). 

Specifically, we are recouping $10 million for each such year through adjustments to the 

chiropractic CPT codes. Payment under the PFS for these codes will be reduced by 

approximately 2 percent. We believe that spreading this adjustment over a longer period of time 

will minimize its potential negative impact on chiropractic practices. 

For the CY 2012 PFS, our Office of the Actuary (OACT) estimated chiropractic 

expenditures to be approximately $470 million, which reflected the statutory 29.4 percent 

reduction to physician payments scheduled to take effect that year. As noted above, the statute 

was subsequently amended to impose a zero percent update for CY 2012 instead of the 29.4 

percent reduction. OACT now estimates CY 2012 chiropractic expenditures to be approximately 

$630 million. We are currently recouping $10 million through adjustments to the chiropractic 

CPT codes in CY 2012, and the percent of this reduction is approximately 1.5 percent. 

We are continuing the implementation of the required BN adjustment by recouping $10 

million in CY 2013. Our Office of the Actuary estimates chiropractic expenditures in CY 2013 

will be approximately $470 million based on Medicare spending for chiropractic services for the 

most recent available year and reflecting an approximate 30.9 percent reduction to physician 

payments scheduled to take effect under current law. To recoup $10 million in CY 2013, the 

payment amount under the PFS for the chiropractic CPT codes (CPT codes 98940, 98941, and 

98942) will be reduced by approximately 2 percent. We are reflecting this reduction only in the 
CMS-1590-P 558 

payment files used by the Medicare contractors to process Medicare claims rather than through 

adjusting the relative value units (RVUs). Avoiding an adjustment to the RVUs would preserve 

the integrity of the PFS, particularly since many private payers also base payment on the RVUs. 

Therefore, as finalized in the CY 2010 PFS regulation and reiterated in the CYs 2011-

2012 PFS regulations, we are implementing this methodology and recouping from the 

chiropractor fee schedule codes set forth above. Our methodology meets the statutory 

requirement for BN and appropriately impacts the chiropractic profession that is directly affected 

by the demonstration. 
CMS-1590-P 559 

K. Physician Value-Based Payment Modifier and the Physician Feedback Reporting Program

1. Value-based Payment Modifier and Physician Feedback Reporting Program Overview of 

Proposals 

 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 

addition, section 1848(p)(4)(B)(iii) of the Act requires the Secretary to apply the payment 

modifier beginning January 1, 2015 to specific physicians and groups of physicians the Secretary 

determines appropriate. This section also requires the Secretary to apply the value-based 

payment modifier for all physicians and groups of physicians (and allows the Secretary to apply 

the value-based payment modifier for eligible professionals as defined in section 1848(k)(3)(B) 

of the Act as the Secretary determines appropriate) beginning not later than January 1, 2017. 

Section 1848(p)(4)(C) of the Act requires the value-based payment modifier to be implemented 

in a budget neutral (BN) manner. 

 Section 1848(n) of the Act requires the Secretary to provide confidential Physician 

Feedback reports to physicians that measure the resources involved in furnishing care to 

Medicare beneficiaries. Section 1848(n)(1)(A)(iii) of the Act also authorizes us to include 

information on the quality of care furnished to Medicare beneficiaries by a physician or group of 

physicians in those reports. 

In developing our proposals for the value-based payment modifier, we have reviewed our 

experience over the past 3 years in providing Physician Feedback reports to certain physicians 

and groups of physicians. The Physician Feedback reports allow us to test different 

methodologies and to obtain stakeholder feedback that can be used to further refine the reports 

and inform our policy proposals and recommendations. We have also linked the Physician 
CMS-1590-P 560 

Feedback reports with the Physician Quality Reporting System (PQRS), by including the quality 

measures physicians and groups of physicians reported in the PQRS program in the 2010 

Physician Feedback reports that we produced and disseminated in 2011 (to groups of physicians) 

and early 2012 (to individual physicians). 

In this proposed rule, we discuss our proposals to implement the value-based payment 

modifier (which will affect payments starting in 2015). These proposals focus on creating value 

for Medicare fee-for-service (FFS) beneficiaries by focusing on prevention and effective chronic 

disease care and by encouraging high quality care for the most difficult cases. The proposals 

recognize that physician quality measurement is still evolving and that our methodologies are 

still developing. We designed our proposals to (1) provide groups of physicians with 25 or more 

eligible professionals an option that their value-based payment modifier be calculated using a 

quality-tiering approach; (2) focus our payment adjustment (both upward and downward) on 

those groups of physicians that are outliers, that is on those that are significantly different from 

the mean; and (3) align the value-based payment modifier with the PQRS and utilize Medicare 

claims data in order to reduce administrative burden on groups of physicians. We believe that 

our proposals are adaptable to smaller groups of physicians and physicians in solo practices that 

will be subject to the value-based payment modifier starting in 2017 and we seek comment on 

the potential for our current proposals to be applied to all physicians and groups of physicians. 

We also encourage physicians and other stakeholders to work with us to include additional 

quality measures (including additional outcome measures) that meaningfully measure the care 

they provide to Medicare beneficiaries. 

 Our proposed scoring methodology for the value-based payment modifier would assess 

quality of care furnished compared to cost during the performance period (which is 2013 for the 

first year) to calculate an adjustment to payments under the PFS during the payment adjustment 
CMS-1590-P 561 

period (which is 2015 for the first year). In light of our desire to align CMS quality 

improvement programs, this methodology relies, in part, on the data submitted on quality 

measures by groups of physicians through the PQRS. Quality measurement is necessary, but not 

sufficient, for quality improvement and a focus on value.5

 To balance our goals of beginning the 

implementation of the value-based payment modifier consistent with the legislative requirements 

and to give us and the physician community experience in its operation, we propose to separate 

all groups of physicians with 25 or more eligible professionals into two categories based on how 

they have chosen to participate in the PQRS. 

The first category includes those groups of physicians that have met the criteria for 

satisfactory reporting of data on PQRS quality measures for the 2013 and 2014 incentives or the 

criteria for satisfactory reporting using the administrative claims-based reporting mechanism, 

which is applicable to the 2015 and 2016 PQRS payment adjustment. These groups of 

physicians will have fulfilled a key condition for quality improvement and a focus on value, that 

is, to measure quality by reporting data on quality measures that can be used to assess quality of 

care furnished. Thus, we propose initially to set the value-based payment modifier at 0.0 percent 

for these groups of physicians, meaning that the value-based payment modifier would not affect 

their payments under the PFS. 

Within this category of satisfactory PQRS reporters, we propose to offer an option that 

their value-based payment modifier be calculated using a quality-tiering approach. This option 

would allow these groups of physicians to earn an upward payment adjustment for high 

performance (high-quality tier and low-cost tier) performance, and to be at risk for a downward 

payment adjustment for poor performance (low-quality tier and high-cost tier). Because of the 

BN requirement and proposed limit on the downward adjustment noted below, we cannot specify 

 

5

 Mark R. Chassin, et al. “Accountability Measures – Using Measurement to Promote Quality Improvement,” N 

Eng. J. of Med. 2010; 363:683-688 (Aug. 2010), available at 

http://www.nejm.org/doi/full/10.1056/NEJMsb1002320. 
CMS-1590-P 562 

the exact amount of the upward payment adjustment for groups of physicians achieving high 

performance. We propose, however, that the maximum downward payment adjustment for these 

groups would be -1.0 percent for poor performance because we recognize that 2015 is the initial 

year for the value-based modifier and we wish to provide for a very modest adjustment for the 

initial years. We believe this methodology would encourage future improvement in terms of 

better value for Medicare beneficiaries without being overly burdensome to groups of physicians 

that requested to have their value-based payment modifier be calculated using the quality-tiering 

approach. 

The second category includes those groups of physicians with 25 or more eligible 

professionals that have not met the PQRS satisfactory reporting criteria identified above, 

including those groups of physicians that have decided not to participate in any PQRS reporting 

mechanism. Because we would not have quality measure performance rates on which to assess 

the quality of care furnished by these groups of physicians, we propose to set their value-based 

payment modifier at -1.0 percent as described in more detail in our proposal below. We note that 

this downward payment adjustment for the 2015 value-based payment modifier would be in 

addition to the -1.5 percent payment adjustment that is assessed under section 1848(a)(8) of the 

Act for failing to meet the satisfactory reporting criteria under PQRS. Therefore, groups of 

physicians with 25 or more eligible professionals that fail to meet the PQRS satisfactory 

reporting criteria would be subject to a downward adjustments during 2015 of 1.5 percent for 

eligible professionals who fail to be satisfactory reporters under the PQRS and 1.0 percent for the 

value-based payment modifier. Because the value-based payment modifier provides upward 

payment adjustments for groups of physicians on the high-quality and lost-cost tiers, we 

encourage groups of physicians with 25 or more eligible professionals to elect that their valuebased payment modifier be calculated using the quality-tiering approach. 
CMS-1590-P 563 

 In this proposed rule, we (1) expand upon our vision of how we see the value-based 

payment modifier helping transform Medicare from a passive payer to an active purchaser of 

higher quality, more efficient healthcare; (2) propose to whom the value-based payment modifier 

would apply starting in CY 2015 in ways that emphasize the value-based payment modifier’s 

focus on increasing quality measurement such that all physicians and groups of physicians would 

be subject to value-based payment modifier starting in CY 2017; (3) propose ways to align the 

value-based payment modifier with the quality measures and reporting requirements established 

under the PQRS; (4) propose how we would score the value-based payment modifier and apply 

the BN requirement in ways that encourage quality reporting through the PQRS; and (5) describe 

how we have used and plan to continue to use the Physician Feedback reports to further inform 

physicians and groups of physicians about their quality of care and resource use. 

2. Value-Based Payment Modifier Overview 

The value-based payment modifier is an important component in revamping how care 

and services are paid for under the PFS that has the potential to help transform Medicare from a 

passive payer to an active purchaser of higher quality, more efficient and effective healthcare. 

We recognize that although the quality of care furnished is high in many regards, this fact 

ignores “[h]ealth care today harms too frequently and routinely fails to deliver its potential 

benefits” to patients.6

 Indeed, the Institute of Medicine has stated that the “health care system as 

currently structured does not, as a whole, make the best use of its resources.”7

 Findings from the 

2010 Physician Feedback reports confirm this statement: high value (high quality and low cost) 

 

6

 Institute of Medicine, “Crossing the Quality Chasm,” (2001) at 1; Elizabeth A. McGlynn, “The Case for Keeping 

Quality on the Health Reform Agenda,” prepared testimony before the Senate Committee on Finance (June 3, 2008), 

available at http://www.rand.org/content/dam/rand/pubs/testimonies/2008/RAND_CT306.pdf 7

 “Crossing the Quality Chasm” at 3. 
CMS-1590-P 564 

can be achieved and there is substantial room for quality improvement and better value.8 We 

believe that the value-based payment modifier can be used to incentivize and reward high 

quality, efficiently furnished care by providing upward payment adjustments under the PFS to 

high performing physicians (and groups of physicians) and downward adjustments for low 

performing physicians (and groups of physicians). 

We recognize, however, that physicians are the forefront of care delivery and that 

changes in payment policy can directly affect medical care that physicians furnish to Medicare 

beneficiaries. Consistent with the National Quality Strategy, our aim is to promote preventive 

care and improve rather than impede the care that beneficiaries currently receive, especially for 

the chronically ill and those with the most complicated cases. Thus, we seek to implement 

payment policies that complement and support “the courage, hard work, and commitment of 

doctors, nurses, and others in health care” to improve the health care systems in which they 

work.9

 

We explained in the CY 2012 PFS proposed rule that Medicare is beginning to 

implement value-based payment adjustments for other types of services, including inpatient 

hospital services (76 FR 42908). We have also developed plans to implement value-based 

purchasing for skilled nursing facilities, home health services and ambulatory surgical center 

services. In implementing value-based purchasing initiatives generally, we seek to meet the 

following goals: 

● Recognize and reward high quality care and quality improvements. 

 ++ Value-based payment systems and public reporting should rely on a mix of standards, 

processes, outcomes, and patient experience measures, including measures of care transitions and 

 

8

 CMS, “Analysis of 2010 Quality and Resource Use Reports for Medical Practice Groups” (2012), available at 

http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeedbackProgram/Downloads/QRURs_for_Medical_Practice_Groups.pdf 9

 “Crossing the Quality Chasm” at 4. 
CMS-1590-P 565 

changes in patient functional status. Across all programs, we seek to move as quickly as possible 

to the use of outcome and patient experience measures. To the extent practicable and 

appropriate, we believe these outcome and patient experience measures should be adjusted for 

risk or other appropriate patient population or provider characteristics. 

 ++ To the extent possible, and recognizing differences in payment system readiness and 

statutory requirements and authorities, measures should be aligned across Medicare and 

Medicaid's public reporting and payment systems. We seek to evolve a focused core set of 

measures appropriate to each specific provider category that reflects the level of care and the 

most important areas of service and measures for that provider. 

 ++ The collection of information should minimize the burden on providers to the extent 

possible. As part of that effort, we will continuously seek to align our measures with the 

adoption of meaningful use standards for health information technology (HIT), so the collection 

of performance information is part of care delivery. 

 ++ To the extent practicable, the measures we use should be nationally endorsed by a 

multi-stakeholder organization. Measures should be aligned with best practices among other 

payers and the needs of the end users of the measures. 

● Promote more efficient and effective care through the use of evidence based measures, 

less rework and duplication, and less fragmented care. 

 ++ Providers should be accountable for the costs of care, being both rewarded for 

reducing unnecessary expenditures and responsible for excess expenditures. 

 ++ In reducing excess expenditures, providers should continually improve and maintain 

the quality of care they deliver. 

 ++ To the extent possible, and recognizing differences in payers' value based purchasing 

initiatives, providers should redesign care processes to deliver higher quality and more efficient 
CMS-1590-P 566 

care to their entire patient population. 

 Because of the centrality of physicians to high-quality, efficient, patient-centered care 

furnished in multiple settings, we believe that in the long run the value-based payment modifier 

should rely on measuring physician performance (both quality of care and cost) at four levels (to 

the extent practicable) – the individual physician level, the group practice level, the facility level 

(for example, hospital), and the community level. Physicians make decisions on a patient-bypatient basis as to what services are indicated and furnished. These decisions are made 

independently by physicians within multiple settings (that is, individual office practice, group 

practice, hospital) and are dependent, in part, on how care is organized in a community. 

Consequently, physicians have the potential to drive both quality of care and costs at all levels of 

the health system and these decisions have an impact on patient outcomes and costs for 

populations of patients. We envision a physician value-based payment modifier in the future that 

blends performance at each of these levels (as applicable) and reinforces our objectives to 

encourage and reward physicians for furnishing high-quality, efficient, patient-centered clinical 

care. 

 To start to implement this long-term vision of the value-based payment modifier, we have 

undertaken numerous activities in the past year to inform our proposals in this rule. We have 

obtained stakeholder input about the content (including the completeness of the quality 

measures) and methodologies we have used in the Physician Feedback reports, as well as input 

on how the private sector has used physician pay-for-performance programs. In particular, we 

conducted five national provider calls about methodologies we have used in the Physician 

Feedback reports and similar private sector initiatives.10 We also held (and continue to hold) 

 

10 See CMS, Physician Feedback Program Teleconferences and Events, available at 

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/CMSTeleconferences-and-Events.html 
CMS-1590-P 567 

numerous sessions with Physician Feedback report recipients (both at the individual and group 

practice level) to obtain additional feedback to improve the methodologies used in the reports. 

 These recent activities complement the work we have undertaken to implement the 

statutory objectives to improve quality of care furnished by physicians and groups of physicians 

to Medicare beneficiaries. For example, the Congress required the Physician Group Practice 

(PGP) Demonstration, which we implemented in 2005. The PGP Demonstration was the first 

pay-for-performance initiative under the Medicare program that involved a shared savings 

model. The demonstration created incentives for physician groups to coordinate the overall care 

furnished to Medicare beneficiaries and rewarded them for improving the quality and cost 

efficiency of health care services. By the fifth year of the demonstration, all 10 of the 

participating physician groups achieved quality benchmark performance on at least 30 of the 32 

measures, and seven of the groups achieved benchmark performance on all 32 performance 

measures. The PGP quality reporting tool and its methodology also became the basis for the 

Group Practice Reporting Option (GPRO) under the PQRS. 

 In 2003, we implemented the Medicare Care Management Performance (MCMP) 

demonstration project. The demonstration showed that small and solo physician practices are 

willing to participate in quality measurement and reporting. Almost 700 physician practices of 

various sizes used a GPRO-like reporting tool to report data on 23 quality measures. 

 In 2006, Congress established what is now known as the Physician Quality Reporting 

System (PQRS), which is a voluntary quality reporting program that, as subsequently amended, 

provides a combination of incentive payments and payment adjustments to eligible professionals 

(including group practices) based on whether they satisfactorily report data on quality measures 

for covered professional services furnished to Medicare Part B FFS beneficiaries. In 2010, 
CMS-1590-P 568 

268,968 eligible professionals11 participated in PQRS in addition to those physicians 

participating in quality reporting through the PQRS GPRO option. 

 Recently, we provided physicians and groups of physicians with confidential Physician 

Feedback reports that provide them with comparative performance data on quality of care they 

furnish compared to costs. Results from the most recent group practice reports show little 

correlation between quality of care furnished and cost for the 35 participating group practices to 

whom we provided reports--high quality can be associated with high or low cost (and vice versa) 

(see Physician Feedback Program discussion below). Moreover, overall results from the 

individual Physician Feedback reports based on 2010 data show that clinical care is highly 

fragmented and there is substantial room for improvement in the quality of care furnished to 

Medicare fee for service beneficiaries. 

 Based on what we have learned from the aforementioned demonstration projects, the 

results from the PQRS and the confidential Physician Feedback reports, and our outreach on the 

national provider calls on private sector programs, we believe the value-based payment modifier 

and the Physician Feedback reports can be used to incentivize and reward high quality, 

efficiently furnished care by providing upward payment adjustments under the PFS to high 

performing physicians and downward adjustments for low performing physicians. To do so, we 

believe the following specific principles should govern the implementation of the value-based 

payment modifier. 

● A focus on measurement and alignment. It is difficult to maintain high quality care 

and improve quality and performance without measurement. Therefore, the value-based 

payment modifier should incorporate performance on more quality measures than those that we 

finalized in the CY 2012 PFS final rule (76 FR 73429 through 73432). These additional 

 

11 Eligible professionals include physicians and non-physicians such as physician assistants and nurse practitioners. 
CMS-1590-P 569 

measures for the value-based payment modifier should consistently reflect differences in 

performance among physicians and physician groups and reflect the diversity of services 

furnished. These measures should be consistent with the National Quality Strategy and other 

CMS quality initiatives, including the PQRS, the Medicare Shared Savings Program, and the 

Medicare EHR Incentive Program. In the proposals described later in this section, we propose to 

expand the quality measures for the value-based payment modifier. We also encourage 

physicians to work with us to include additional quality measures (including outcome measures) 

that meaningfully measure the care they furnish to Medicare beneficiaries. 

● A focus on physician choice. Physicians should be able to choose the level at which 

their performance will be assessed reflecting physicians’ choice over their practice 

configurations. The choice of level should align with the requirements of other physician quality 

reporting programs, such as the PQRS and the Medicare EHR Incentive program to reduce 

administrative burden and encourage greater program participation. In the proposals described 

later in this section, we propose to rely on the quality measure data collected through the PQRS 

Group Practice Reporting Option (GPRO) and Medicare EHR Incentive Program to obtain most 

of the performance data for the value-based payment modifier. 

 

● A focus on shared accountability. CMS has 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 believe that the value-based payment modifier can facilitate shared accountability 

by assessing performance at the practice group level and by focusing on the total costs of care, 

not just the costs of care furnished by an individual physician. In the proposals described later in 

this section, we propose to use performance on several outcome measures that we will calculate 

for physicians reporting measures at the group level that encourage them to seek innovative ways 
CMS-1590-P 570 

to furnish high-quality, patient-centered, and efficient care to the Medicare FFS patients they 

treat. We also seek to start a discussion on how best to incorporate individual, hospital-based, 

and community-based quality and cost measures as a component of the value-based payment 

modifier so that we align quality measurement strategies across providers and settings of care. 

● A focus on actionable information. In conjunction with adjusting payment based on 

performance, CMS should provide meaningful and actionable information to help physicians 

identify clinical areas where they are doing well as well as areas in which performance could be 

improved. The Physician Feedback reports can serve this purpose. In the proposals described 

later in this section, we propose ways to provide additional feedback to physicians and groups of 

physicians through the Physician Feedback reports. 

● A focus on a gradual implementation. We believe that the value-based payment 

modifier should focus initially on outliers (that is, those groups of physicians that are 

demonstrably high or low performers as compared to their peers that treat like beneficiaries). 

We also believe that groups of physicians should be able to elect how the value-based payment 

modifier would apply to their payment under the PFS starting in 2015 as we phase in the valuebased payment modifier. As we gain more experience with physician measurement tools and 

methodologies, we can broaden the scope of measures assessed to organize them around medical 

condition, refine physician peer groups to focus on how like beneficiaries are treated, create finer 

payment distinctions that focus on increasing value, and provide greater payment incentives for 

high performance. In the proposals described later in this section, we propose to allow groups of 

physicians with 25 or more eligible professionals to elect how the value-based payment modifier 

would be applied to them under the PFS starting in 2015. We also propose a scoring 

methodology that can identify outliers (both high and low performers) and is flexible to 

accommodate these future goals. 
CMS-1590-P 571 

 We seek comment on these principles as guides to our implementation of the valuebased payment modifier. 

3. Proposals for the Value-Based Payment Modifier 

In the following sections, we describe our proposals for each component of the valuebased payment modifier. These components include: the quality measure reporting methods; 

the quality and cost measures; the attribution methodology; the payment adjustment amount; the 

scoring methodology; and the review and inquiry process. Following the discussion of these 

components, we summarize how the components would work together for a group of physicians 

with 25 or more eligible professionals that submits data on quality measures using the PQRS 

GPRO web-interface and requests that their value-based payment modifier be calculated using 

the quality-tiering approach. 

a. Proposed Application of the Value-Based Payment Modifier 

 Section 1848(p)(4)(B)(iii) of the Act requires the Secretary to apply the value-based 

payment modifier to items and services furnished 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. For purposes of this 

proposed rule, physicians are defined in section 1861(r) of the Act to include doctors of 

medicine or osteopathy, doctors of dental surgery or dental medicine, doctors of podiatric 

medicine, doctors of optometry, and chiropractors. 

 We propose to initially include all groups of physicians with 25 or more eligible 

professionals in the value-based payment modifier. For purposes of establishing group size, we 

propose to 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; (3) a physical or occupational 
CMS-1590-P 572 

therapist or a quality speech-language pathologist; or (4) a qualified audiologist. In addition, we 

propose to define a group of physicians as “a single Tax Identification Number (TIN) with 25 or 

more eligible professionals, as identified by their individual National Provider Identifier (NPI), 

who have reassigned their Medicare billing rights to the TIN.” We chose these groups of 

physicians in order to align with the reporting requirements for group practices and the 

definitions used in the PQRS. We also propose to assess whether a group of physicians has 25 or 

more eligible professionals at the time the group of physicians is selected to participate under the 

PQRS GPRO. 

 We propose to apply the value-based payment modifier to the Medicare paid amounts for 

the items and services billed under the PFS at the TIN level so that beneficiary cost-sharing or 

coinsurance would not be affected. We also propose to apply the value-based payment modifier 

to the items and services billed by eligible professionals who are physicians under the TIN, not 

to other eligible professionals that also may bill under the TIN. 

 In addition, application of the value-based payment modifier at the TIN level means that 

we would not “track” or “carry” a physician’s performance from one TIN to another TIN. In 

other words, if a physician changes groups from TIN A in the performance period (2013) to TIN 

B in the payment adjustment period (2015), we would apply TIN B’s value-based payment 

modifier to the physician’s payments for items and services billed under TIN B during 2015. We 

are making this proposal for two reasons. First, payment at the group practice (TIN level) 

reflects the view that the group in which a physician practices matters. Second, we believe it 

will be more straightforward for groups of physicians to understand how the value-based 

payment modifier affects their TIN’s payment in the payment adjustment period if all physician 

billing under the TIN receive the same value-based payment modifier. We seek comment on 

these proposals. 
CMS-1590-P 573 

It is critical to note that our proposals would allow groups of physicians with 25 or more 

eligible professionals to decide how the value-based payment modifier would be applied to their 

PFS payments. In light of our desire to align CMS quality improvement programs, this 

methodology relies, in part, on the data submitted on quality measures by groups of physicians 

through the PQRS. Quality measurement is necessary, but not sufficient, for quality 

improvement and a focus on value. We propose to separate all groups of physicians with 25 or 

more eligible professionals into two categories based on how they have chosen to participate in 

the PQRS. 

The first category includes those groups of physicians with 25 or more eligible 

professionals that have met the proposed criteria for satisfactory reporting of data on PQRS 

quality measures for the 2013 and 2014 incentive or the proposed criteria for satisfactory 

reporting using the administrative claims-based reporting mechanism, which is applicable to the 

2015 and 2016 PQRS payment adjustment. These groups of physicians will have fulfilled a key 

condition for quality improvement and a focus on value, that is, to measure quality by submitting 

and/or having data on quality measures that can then be used to assess quality of care furnished. 

We propose initially to set the value-based payment modifier at 0.0 percent for these groups of 

physicians, meaning that the value-based payment modifier would not affect their payments 

under the PFS. We point out that in order for a group of physicians to meet the satisfactory 

reporting criteria, the group of physicians must first self-nominate as a group as described above 

in Section III.G.1.b.2 of this proposed rule regarding the PQRS. 

Within this category of satisfactory PQRS reporters, we propose to offer an option that 

their value-based payment modifier be calculated using the quality-tiering approach described 

below in subsection (h) Proposed Value-Based Payment Modifier Scoring Methodology. Under 

these proposals, groups of physicians could earn an upward payment adjustment for high 
CMS-1590-P 574 

performance (high-quality tier compared to low-cost tier) performance, and be at risk for a 

downward payment adjustment for poor performance (low-quality tier compared to high-cost 

tier). We seek comment, however, on whether to calculate the value-based payment modifier for 

all groups of physicians that are satisfactory PQRS reporters using the quality-tiering approach 

described in subsection (h) below, rather than providing an option for such groups of physicians 

to request that we do so. 

The second category includes those groups of physicians with 25 or more eligible 

professionals that have not met the PQRS satisfactory reporting criteria identified above. Under 

our proposal, a group of physicians could fail to meet the PQRS satisfactory reporting criteria 

because the group of physician decided not to participate in any PQRS reporting mechanism or 

because the group attempted to submit data, but failed to meet the criteria to become a 

satisfactory reporter (e.g., did not report data appropriately on the requisite number of 

beneficiaries or measures). Because we would not have quality measure performance rates on 

which to assess the quality of care furnished by these groups, we propose to set their value-based 

payment modifier at -1.0 percent, meaning they would receive 99.0 percent of the paid amounts 

for the items and services billed under the PFS. 

 We believe this approach is a reasonable way to phase in the value-based payment 

modifier because groups of physicians have demonstrated their ability to submit data on quality 

measures at the group level using the PQRS GPRO since 2011. And for 2012, we revised the 

eligibility criteria for the PQRS GPRO to include groups with at least 25 eligible professionals. 

Thus, we believe that these groups of physicians have had sufficient opportunity to make an 

informed decision about submitting data on quality measures that also could be used in the 

value-based payment modifier starting in 2015. 

 Moreover, section 1848(p)(5) of the Act requires us to, as appropriate, apply the value-
CMS-1590-P 575 

based payment modifier “in a manner that promotes systems-based care.” In this context, 

systems-based care is the processes and workflows that (1) make effective use of information 

technologies, (2) develop effective teams, (3) coordinate care across patient conditions, services, 

and settings over time, and (4) incorporate performance and outcome measurements for 

improvement and accountability.12 We believe that groups of physicians have the ability and 

the resources to redesign such processes and workflows to achieve these objectives and furnish 

high-quality and cost-effective clinical care. 

 Starting in 2017, we would apply the value-based payment modifier to all physicians 

and groups of physicians as required by the statute. We seek comment on whether we should 

offer individual physicians and groups of physicians with fewer than 25 eligible professionals 

an option that their value-based payment modifier be calculated using a quality-tiering approach 

starting in 2015. If we did so, we could calculate a value-based payment modifier for groups of 

physicians with as few as two eligible professionals and apply the value-based payment 

modifier at the TIN level in the manner described in these proposals for groups of 25 or more 

eligible professionals. Likewise, we seek comment on how to adapt our proposals to calculate a 

value-based payment modifier at the TIN level for physicians in solo practices (TINs comprised 

of one NPI). 

 We also seek comment on whether we should develop a value-based payment modifier 

option for hospital-based physicians to elect to be assessed based on the performance of the 

hospital at which they are based. In particular, hospital performance could be assessed using the 

measure rates the hospitals report on the quality measures in the Inpatient Quality Reporting 

(IQR) and the Outpatient Quality Reporting (OQR) programs. If so, we seek comment on which 

 

12 Johnson JK, Miller SH, Horowitz SD. Systems-based practice: Improving the safety and quality of patient care by 

recognizing and improving the systems in which we work. In: Henriksen K, Battles JB, Keyes MA, Grady ML, 

editors. Advances in Patient Safety: New Directions and Alternative Approaches, Vol 2: Culture and Redesign. 

AHRQ Publication No. 08-0034-2. Rockville, MD: Agency for Healthcare Research and Quality; August 2008. p. 

321-330. 
CMS-1590-P 576 

IQR and OQR measures (and the applicable reporting period) would be appropriate to include in 

such an option and a way to identify and verify whether physicians are hospital-based. The IQR 

measures can be found at 

http://qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2

&cid=1141662756099 and the OQR measures can be found at 

http://qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2

&cid=1196289981244. 

 In addition, we seek comment on how best to ascertain whether a group of physicians 

with 25 or more eligible professionals requests the option that their value-based payment 

modifier be calculated using a quality-tiering approach. We seek to establish a system that 

reduces administrative burden on physicians, enables these groups of physicians to indicate how 

they plan to submit data on quality measures through the PQRS, and is easy to administer. We 

could, for example, build off of the self-nomination process that we have proposed for groups of 

physicians to participate in the PQRS GPRO. As discussed in Section III.G.1.b.2 of this 

proposed rule regarding the PQRS, we anticipate that we will have the ability to collect selfnomination statements via the web in 2013. As proposed above, these self-nomination 

statements would be submitted by January 31, 2013 for the 2013 performance period. In the 

event that the web-based functionality is unable to accept self-nomination statements for 2013, 

we have proposed that groups of physicians submit a self-nomination statement via a letter (in a 

prescribed format) to CMS in a timely manner. 

 We also could establish a separate web-based registration system that permits groups of 

physicians to , throughout calendar year 2013, request that their value-based payment modifier 

be calculated using the quality-tiering approach (rather than submit a self-nomination statement 

by January 31, 2013 as proposed in the PQRS self-nomination process). Another approach 
CMS-1590-P 577 

would be to require that groups of physicians submit a letter (in a prescribed format) to CMS in 

a timely manner. We seek comment on these approaches. 

 We propose not to offer groups of physicians with 25 or more eligible professionals that 

are participating in the Medicare Shared Savings Program or are associated with the Pioneer 

ACO program, assuming they meet the PQRS satisfactory reporting criteria, the option that their 

value-based payment modifier be calculated using the quality-tiering approach. As of April 

2012, 27 ACOs are participating in the Shared Savings Program, and 32 ACOs are participating 

in the Pioneer ACO program. We anticipate more ACOs will enter the Medicare Shared 

Savings Program beginning July 1, 2012, and on January 1st annually thereafter. Shared 

Savings Program ACOs will be in a “pay for reporting” mode in 2013, while Pioneer ACOs will 

be in a “pay for performance” mode in 2013. 

 We make this proposal because we are mindful that the physicians and groups of 

physicians that are, or will be, participating in the Shared Savings Program and the Pioneer 

ACO program have made sizable investments to redesign care processes based on the incentives 

created by these programs. Indeed, these organizations have committed to reporting on a 

broader set of quality measures than we are proposing for the value-based payment modifier to 

demonstrate the quality of care their beneficiaries are receiving. We do not wish to 

unintentionally disturb these investments. Therefore, we seek comment on ways to structure the 

value-based payment modifier starting in 2017 so it does not create incentives that conflict with 

the goals of the Shared Savings Program and the Pioneer ACO program. Alternatively, we seek 

comment on whether we should permit groups of physicians that are participating in these two 

programs the option that their value-based payment modifier be calculated using a qualitytiering approach and applied to their payments under the PFS starting in 2015. 

 We note that the value-based payment modifier is applicable only to payment for 
CMS-1590-P 578 

physicians’ services under the PFS. The value-based payment modifier does not apply to 

services that physicians furnish in Rural Health Clinics (RHCs), Federally Qualified Health 

Centers (FQHCs), and Critical Access Hospitals (CAHs) billing under method II (but not 

method I or the standard method), because they are not considered as being paid under the PFS. 

b. Proposed Performance Period 

We previously finalized CY 2013 as the initial performance period for the value-based 

payment modifier that will be applied in CY 2015 (76 FR 73436). This means that we will use 

performance on quality and cost measures during CY 2013 to calculate the value-based 

payment modifier that we would apply to items and services for which payment is made under 

the PFS during CY 2015. Likewise, we propose that performance in CY 2014 be used to 

calculate the value-based payment modifier that is applied to items and services for which 

payment is made under the PFS during CY 2016. 

 As we explained previously in the CY 2012 PFS final rule with comment period (76 FR 

73435), we explored different options to close the gap between the performance period (that is, 

2013) and the payment adjustment period (that is, 2015), but that none of them would have 

permitted sufficient time for physicians and groups of physicians to report measures or have 

their financial performance measured over a meaningful period, or for us to calculate a valuebased payment modifier and notify physicians and groups of physicians of their quality and cost 

performance and value-based payment modifier prior to the payment adjustment period. We 

also explained that a system that adjusted payments to take into account the value-based 

payment modifier after claims have been paid would be onerous on physicians and 

beneficiaries. We continue to explore ways to provide more timely feedback to physicians and 

to narrow the gap between the performance period and the payment adjustment period and seek 

comment on practical alternatives that we could implement to do so. We seek comment on our 
CMS-1590-P 579 

proposal to use CY 2014 as the performance period for the 2016 value-based payment modifier. 

c. Proposed Quality Measures 

In this section we discuss our proposals to align quality measure reporting for the valuebased payment modifier with PQRS reporting methods, to expand the range of quality measures 

that we will use for the value-based payment methodology, and to start a discussion on how to 

assess community based quality of care. 

(1) Alignment of Quality Reporting Options with PQRS Satisfactory Reporting Criteria 

As discussed above, we propose to categorize groups of physicians with 25 or more 

eligible professionals into two categories depending upon whether they have met the PQRS 

satisfactory reporting criteria established above for the value-based payment modifier. We note 

that under those proposed criteria for satisfactory reporting, groups of 25 or more eligible 

professionals would be able to submit data on quality measures using one of following proposed 

PQRS reporting mechanisms: PQRS GPRO using the web-interface, claims, registries, or EHRs; 

or PQRS administrative claims-based option. These reporting mechanisms are discussed above 

in Section III.G of this proposed rule (Physician Payment, Efficiency, and Quality Improvement 

– Physician Quality Reporting System). The satisfactory reporting criteria for the PQRS GPRO 

reporting mechanisms are described in Tables 27 and 28. The satisfactory reporting criteria for 

the PQRS administrative claims-based reporting option is described in Section III.G. (“Proposed 

Criteria for Satisfactory Reporting for the 2015 and 2016 Payment Adjustments for Eligible 

Professionals and Group Practices using the Administrative Claims-based Reporting 

Mechanism.”) We propose to rely on these proposed criteria for satisfactory reporting in order to 

categorize groups of physicians for purposes of the value-based payment modifier. 

 For those groups of physicians that have met the PQRS satisfactory reporting criteria and 

request that their value-based payment modifier be calculated using a quality-tiering approach, 
CMS-1590-P 580 

we propose to use the performance rates on the quality measures reported through any of these 

reporting mechanisms. We seek comment on this proposal. We are concerned, however, that 

some groups of physicians may attempt to submit data on PQRS quality measures using one of 

the GPRO reporting mechanisms (web-interface, claims, registries, or EHRs) and fail to meet the 

criteria for satisfactory reporting and thus be categorized as non-PQRS reporters (and be subject 

to the -1.0 percent downward adjustment). To address this issue, we seek comment on whether 

to assess performance on the measures included in the PQRS administrative claims-based 

reporting option as a default if a group of physicians attempts to participate in one of the PQRS 

GPRO reporting mechanisms and does not meet the PQRS criteria for satisfactory reporting. 

In addition, we seek comment on which PQRS reporting mechanisms we should offer to 

individual physicians if we were to apply the value-based payment modifier applied to their 

payments under the PFS starting in 2015 or 2016. Tables 25 and 26 describe the proposed PQRS 

reporting options available to individual physicians for the 2013 and 2014 PQRS incentives. 

(2) Quality Measure Alignment with the Physician Quality Reporting System 

 In the CY 2012 PFS final rule with comment period (76 FR 73432), we finalized, for 

physicians practicing in groups, all measures in the GPRO of PQRS for 2012. We also stated 

that we expected to update these measures for the initial performance year (CY 2013) of the 

value-based payment modifier based on the measures finalized in subsequent rulemaking under 

PQRS. (76 FR 73427 through 73432). We propose to include all individual measures in the 

PQRS GPRO web-interface, claims, registries, and EHR reporting mechanisms for 2013 and 

beyond for the value-based payment modifier. These quality measures are included in Tables 30 

and 32. We seek comment on this proposal. 

 We also seek comment on the quality measures that we should propose for individual 

physicians if we were to provide individual physicians the ability to elect to have the value-based 
CMS-1590-P 581 

payment modifier apply to their payments under the PFS starting in 2015 or 2016. In the CY 

2012 PFS final rule with comment period, we finalized for individual physicians, the PQRS core 

set of measures for CY 2012 and the core set of measures, alternate core, and additional 

measures in the Medicare EHR Incentive Program for 2012. We seek comment on which PQRS 

measures for 2013 and beyond to include in calculating the value-based payment modifier at the 

individual level. Table 32 lists the PQRS measures we are proposing for reporting through 

PQRS for 2013 and beyond. We believe incorporating all the PQRS measures provides a broad 

set of quality measures from which physicians can choose how best to assess their performance. 

We seek comment on these issues and the above proposals. 

 (3) Administrative Claims Option under PQRS 

Under the PQRS, we propose to provide an option for physicians and groups of 

physicians to select an administrative claims-based reporting option for purposes of the PQRS 

payment adjustment for 2015 and 2016 only. We discuss two issues surrounding this proposed 

administrative claims-based reporting option as it relates to the value-based payment modifier: 

(1) the level at which to assess the administrative claims-based measures (individual or group), 

and (2) the scope of quality measures that will be assessed using administrative claims. 

(a.) Level of Performance Assessment 

 We can either assess performance at the individual physician level, as we did in the 2010 

individual Physician Feedback reports, or at the group practice level and apply the performance 

rate to the physicians that are part of that group. Measurement and assessment at the individual 

level (as identified by a National Provider Identification number (NPI)) provides actionable 

information for improvement for physicians and can incentivize physician accountability for 

quality of care and cost. Despite these benefits, assessments of individual physicians using 

administrative claims-based measures may result in insufficient numbers of cases at the 
CMS-1590-P 582 

individual level to develop statistically reliable performance rates for each measure. Moreover, 

because physician performance would affect payment, we believe performance rates should be 

statistically reliable. 

 Assessment of physician performance at the group practice level (as identified by a single 

Taxpayer Identification Number (TIN)) reflects the view that the group in which a physician 

practices matters.13 Group practice assessments will allow for a larger number of cases to assess 

performance scores and a larger number of outcome measures than assessments solely at the 

individual level. The larger number of cases also means the performance scores will be more 

statistically reliable on which to modify payment. It also allows us to calculate more quality 

measures in more domains of the National Quality Strategy. For these reasons, for purposes of 

the value-based payment modifier, we propose to assess performance rates for the measures in 

the PQRS administrative claims-based reporting option at the TIN level and apply the calculated 

performance score and the resulting value-based payment modifier to all physicians that bill 

under that TIN during the payment adjustment period. We seek comment on this proposal. 

(b.) Quality Measures 

In the CY 2010 individual Physician Feedback reports, which we distributed to over 

23,000 physicians in Iowa, Kansas, Missouri, and Nebraska in March 2012, we provided 

performance rates on 28 administrative claims-based measures. These measures focused on 

clinical care of prevalent and chronic diseases among Medicare beneficiaries and medication 

management measures and were assessed at the individual physician level (that is, NPI). 

Twenty-seven of the 28 measures were endorsed by the National Quality Forum and the 

remaining measure was developed and is maintained by the National Committee for Quality 

 

13 See e.g., Johnson JK, Miller SH, Horowitz SD. Systems-based practice: Improving the safety and quality of 

patient care by recognizing and improving the systems in which we work. In: Henriksen K, Battles JB, Keyes MA, 

Grady ML, editors. Advances in Patient Safety: New Directions and Alternative Approaches, Vol 2: Culture and 

Redesign. AHRQ Publication No. 08-0034-2. Rockville, MD: Agency for Healthcare Research and Quality; August 

2008. p. 321-330. 
CMS-1590-P 583 

Assurance (NCQA). Specifications for all 28 administrative claims-based measures can be 

found at https://www.cms.gov/physicianfeedbackprogram. 

We propose to include, for purposes of assessing performance for the PQRS 

administrative claims-based reporting option, 15 of these measures, which are indicated in Table 

64. We have selected these 15 measures because they are clinically meaningful, focus on highly 

prevalent conditions among beneficiaries, have the potential to differentiate physicians, and are 

reliable. Most of the proposed measures do not rely on the use of Part D drug data that we do not 

have for all Medicare FFS beneficiaries. We also note that these proposed measures are similar 

to the measures adopted in several private sector programs.14 We also seek comment, however, 

on whether to include any of the remaining 13 measures that we have not proposed, but included 

in the Physician Feedback Reports. These measures are listed in Table 65. 

TABLE 64: Proposed Measures for the Administrative Claims Option for 2015 and 2016

NQF 

Number 

Measure Title Measure 

Steward 

Domain of 

Care 

0576 Follow-Up After Hospitalization for Mental Illness 

Percentage of discharges for patients who were hospitalized for treatment of selected mental 

health disorders and who had an outpatient visit, an intensive outpatient encounter, or partial 

hospitalization with a mental health practitioner

NCQA Care 

Coordination 

0021 Annual Monitoring for Beneficiaries on Persistent Medications 

Percentage of patients 18 years of age and older who received at least 180 treatment days of 

ambulatory medication therapy for a select therapeutic agent during the measurement year and 

at least one therapeutic monitoring event for the therapeutic agent in the measurement year.

NCQA Patient 

Safety 

0555 Lack of Monthly INR Monitoring for Beneficiaries on Warfarin 

Average percentage of 40-day intervals in which Part D beneficiaries with claims for warfarin 

do not receive an INR test during the measurement period.

CMS Patient 

Safety 

0577 Use of Spirometry Testing to Diagnose COPD 

Percentage of patients at least 40 years old who have a new diagnosis or newly active chronic 

obstructive pulmonary disease (COPD) who received appropriate spirometry testing to 

confirm the diagnosis.

NCQA Clinical Care 

0549 Pharmacotherapy Management of COPD Exacerbation 

Percentage of chronic obstructive pulmonary disease (COPD) exacerbations for patients 40 

years of age and older who had an acute inpatient discharge or ED encounter between January 

1–November 30 of the measurement year and were dispensed appropriate medications

NCQA Clinical Care

0543 Statin Therapy for Beneficiaries with Coronary Artery Disease 

Medication Possession Ratio (MPR) for statin therapy for individuals over 18 years of age 

with coronary artery disease.

CMS Clinical Care

0583 Lipid Profile for Beneficiaries Who Started Lipid-Lowering 

Medications 

Percentage of patients age 18 or older starting lipid-lowering medication during the 

measurement year who had a lipid panel checked within 3 months after starting drug therapy

Resolution 

Health 

Clinical Care

0053 Osteoporosis Management in Women ≥ 67 Who Had a Fracture 

Percentage of women 67 years and older who suffered a fracture and who had either a bone 

mineral density (BMD) test or prescription for a drug to treat or prevent osteoporosis in the six 

NCQA Clinical Care

 

14 Zirui Song, et al, “Health Care Spending and Quality in Year 1 of the Alternative Quality Contract,” New England 

Journal of Medicine, 365:10 (Sept. 2011). 
CMS-1590-P 584 

NQF 

Number 

Measure Title Measure 

Steward 

Domain of 

Care 

months after the date of fracture.

0055 Dilated Eye Exam for Beneficiaries ≤ 75 with Diabetes 

Percentage of adult patients with diabetes aged 18-75 years who received a dilated eye exam 

by an ophthalmologist or optometrist during the measurement year, or had a negative retinal 

exam (no evidence of retinopathy) by an eye care professional in the year prior to 

themeasurement year.

NCQA Clinical Care

0057 HbA1c Testing for Beneficiaries ≤ 75 with Diabetes 

Percentage of adult patients with diabetes aged 18-75 years receiving one or more A1c test(s) 

per year.

NCQA Clinical Care

0062 Urine Protein Screening for Beneficiaries ≤ 75 with Diabetes 

Percentage of adult diabetes patients aged 18-75 years with at least one test nephropathy 

screening test during the measurement year or who had evidence existing nephropathy 

(diagnosis of nephropathy or documentation of microalbuminuria or albuminuria).

NCQA Clinical Care

0063 Lipid Profile for Beneficiaries ≤ 75 with Diabetes 

Percentage of adult patients with diabetes aged 18-75 who had an LDL-C test performed 

during the measurement year.

NCQA Clinical Care

0075 Lipid Profile for Beneficiaries with Ischemic Vascular Disease 

Percentage of patients 18 years of age and older who were discharged alive for acute 

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

interventions (PCI) from January 1–November 1 of the year prior to the measurement year, or 

who had a diagnosis of ischemic vascular disease (IVD) during the measurement year and the 

year prior to measurement year, who had a complete lipid profile during the measurement 

year.

NCQA Clinical Care

0105 Antidepressant Treatment for Depression 

Percentage of discharges for patients who were hospitalized for treatment of selected mental 

health disorders and who had an outpatient visit, an intensive outpatient encounter, or partial 

hospitalization with a mental health practitioner.

NCQA Clinical Care

0031 Breast Cancer Screening for 

Women ≤ 69 

Percentage of eligible women 40-69 who receive a mammogram in during the measurement 

year or in the year prior to the measurement year.

NCQA Clinical Care 

TABLE 65: Remaining Measures Not Proposed for the Administrative Claims Option

NQF 

Number 

Measure Title Measure 

Steward 

Domain 

of Care 

Not NQF 

Endorsed 

Potentially Harmful Drug-Disease Interactions in the Elderly 

The percentage of Medicare members 65 years of age and older who have evidence of an 

underlying disease, condition or health concern and who were dispensed an ambulatory 

prescription for a contraindicated medication, concurrent with or after the diagnosis. 

NCQA Patient 

Safety 

0071 

Acute Myocardial Infarction (AMI): Persistence of Beta-Blocker 

Treatment After a Heart Attack

Percentage of patients age 18 years and older during the measurement year who were 

hospitalized and discharged alive with a diagnosis of acute myocardial infarction (AMI) and 

who received persistent beta-blocker treatment for six months after discharge 

NCQA Clinical 

Care 

0022 

Use of High-Risk Medications in the Elderly: (a) Patients Who Receive 

At Least One Drug To Be Avoided 

Percentage of patients ages 65 years and older who received at least one high-risk medication in 

the measurement year 

(b) Patients Who Receive At Least Two Different Drugs To Be Avoided 

Percentage of patients 65 years of age and older who received at least two different high-risk 

medications in the measurement year 

NCQA Patient 

Safety 

0556 

INR for Beneficiaries Taking Warfarin and Interacting Anti-Infective 

Medications

Percentage of episodes with an INR test performed 3 to 7 days after a newly-started interacting 

anti-infective medication for Part D beneficiaries receiving warfarin

CMS Patient 

Safety 

0568 

Appropriate Follow-Up for Patients with HIV 

Percentage of patients diagnosed with HIV who received a CD4 count and an HIV RNA level 

laboratory test in the 6 months following diagnosis 

Health 

Benchmarks 

Clinical 

Care 

0623 

Breast Cancer – Cancer Surveillance 

Percentage of female patients 18 and older with breast cancer who had breast cancer 

surveillance in the past 12 months 

Active 

Health 

Management 

Clinical 

Care 
CMS-1590-P 585 

NQF 

Number 

Measure Title Measure 

Steward 

Domain 

of Care 

0625 

Prostate Cancer – Cancer Surveillance 

Percentage of males with prostate cancer that have had their PSA monitored in the past 12 

months 

Active 

Health 

Management 

Clinical 

Care 

0054 

Arthritis: Disease Modifying Antirheumatic Drug (DMARD) Therapy in 

Rheumatoid Arthritis 

Percentage of patients 18 years and older, diagnosed with rheumatoid arthritis who have had at 

least one ambulatory prescription dispensed for a DMARD 

NCQA Clinical 

Care 

0581 

Deep Vein Thrombosis Anticoagulation At Least 3 Months 

Percentage of patients diagnosed with a lower extremity DVT more than 3 months prior to the 

end of the measurement year (who do not have contraindications to warfarin therapy and who do 

not have an IVC filter in the 90 days after the onset of PE) who had at least 3 months of 

anticoagulation after the event or patients showing compliance with anticoagulation therapy as 

indicated by a Home PT Monitoring device or multiple instances of prothrombin time testing 

over the 3-month period 

Resolution 

Health 

Clinical 

Care 

0593 

Pulmonary Embolism Anticoagulation At Least 3 Months 

Percentage of patients diagnosed with a PE more than 3 months prior to the end of the 

measurement year (who do not have contraindications to warfarin therapy and who do not have 

an IVC filter in the 90 days after the onset of PE) who had at least 3 months of anticoagulation 

after the event or patients showing compliance with anticoagulation therapy as indicated by a 

Home PT Monitoring device or multiple instances of prothrombin time testing over the 3-month 

period 

Resolution 

Health 

Clinical 

Care 

0614 

Steroid Use – Osteoporosis Screening 

Percentage of patients, 18 and older, who have been on chronic steroids for at least 180 days in 

the past 9 months and who had a bone density evaluation or osteoporosis treatment 

Active 

Health 

Management 

Clinical 

Care 

0567 

Appropriate Work-Up Prior To Endometrial Ablation Procedure 

Percentage of women who had an endometrial ablation procedure during the measurement year 

who received endometrial sampling or hysteroscopy with biopsy during the previous year 

Active 

Health 

Management 

Clinical 

Care 

0584 Hepatitis C: Viral Load Test 

Percentage of patients 18 years or older with Hepatitis C (HCV) who began HCV antiviral 

therapy during the measurement year and had HCV Viral Load testing prior to initiation of 

antiviral therapy 

Resolution 

Health 

Clinical 

Care 

(4) Outcome Measures for Groups of Physicians 

 We finalized in the CY 2012 PFS final rule (76 FR 73432) for physicians practicing in 

groups to include the rates of potentially preventable hospital admissions for two ambulatory 

care sensitive conditions (ACSCs) at the group practice level: heart failure; and chronic 

obstructive pulmonary disease. We also noted that several commenters to the CY 2012 proposed 

PFS rule expressed support for using outcome measures that assess the rate of potentially 

preventable hospital admissions including the Consumer-Purchaser Disclosure Project, a group 

of large purchasers of health care services. We believe it is appropriate to focus on potentially 

preventable hospital admissions because, as our 2010 Physician Feedback reports have shown, 

hospital inpatient, outpatient, and emergency department costs account for over 50 percent of 

total per capita costs. Thus, we propose to include four outcome measures in the value-based 
CMS-1590-P 586 

payment modifier for all groups of physicians with 25 or more eligible professionals. These 

outcome measures are discussed below. It is important to note that we propose to calculate these 

measures for groups of physicians with 25 or more eligible professionals regardless of which 

reporting mechanisms the groups of physicians choose to report quality data: PQRS GPRO 

using the web-interface, claims, registries, or EHRs; or the PQRS administrative claims-based 

reporting option. 

 Currently the Physician Feedback reports that we provide to group practices include 

potentially preventable hospital admission measures for three chronic conditions: heart disease, 

chronic pulmonary obstructive disease, and diabetes (a composite measure including 

uncontrolled diabetes, short term diabetes complications, long term diabetes complications and 

lower extremity amputation for diabetes). In addition, the Physician Feedback reports provide 

potentially preventable hospital admission measures for three acute conditions: dehydration; 

urinary tract infection; and bacterial pneumonia. Specifications for all six of these measures can 

be found at http://www.qualityindicators.ahrq.gov/Modules/PQI_TechSpec.aspx. 

 However, given the potential that any group of physicians may have relatively few 

potentially preventable hospital admissions for a given condition, we propose to create for the 

value-based payment modifier two composites from these measures: an acute condition 

composite; and a chronic care composite. Compositing measures is a well-established technique 

in quality measurement to increase reliability when the number of cases is small because it 

combines individual measures into one composite measure. Additionally, presenters on the 

National Provider Calls CMS held on February 29 and March 14 entitled “Physician ValueBased Payment Modifier Program: Experience from Private Sector Physician Pay-forPerformance Programs” specifically recommended this approach for the value-based payment 

modifier. (Transcripts and slides from these presentations are available at 
CMS-1590-P 587 

http://www.cms.gov/physicianfeedbackprogram.) 

 We propose that the acute condition composite combine the rates of potentially 

preventable hospital admission for dehydration, urinary tract infection, and bacterial pneumonia. 

We propose that the chronic care composite combine the rates of potentially preventable hospital 

admissions for diabetes, heart failure, and chronic obstructive pulmonary disease. We believe 

group practices will be incentivized to prevent these types of hospital admissions, which will 

improve patient care and reduce per capita costs. 

 We also propose to use two other quality measures to assess care coordination at the 

group level that we currently use in other CMS physician quality programs: the all-cause 

hospital readmission measure used in the Medicare Shared Savings Program (described on the 

CMS Website at http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/sharedsavingsprogram/Downloads/ACO_QualityMeasures.pdf) and the 30-day postdischarge visit measure used in the PGP Transition Demonstration (described at 

https://www.cms.gov/Medicare/DemonstrationProjects/DemoProjectsEvalRpts/downloads//PGP_Transition_Quality_Specs_Report.pdf). We 

believe that the all-cause hospital readmission measure provides a strong incentive for groups to 

focus on reducing hospital readmissions. In addition, the 30-day post-discharge visit measure 

helps incentivize physicians to engage in more effective care coordination. Recent literature 

cites a study in which there was no visit to a physician's office between the time of discharge and 

rehospitalization for 50 percent of patients who were rehospitalized within 30 days after a 

medical discharge to the community.15 Based on input and comments from stakeholders, 

including other payers, we believe that such follow up visits can reduce unnecessary 

rehospitalizations. These four measures are summarized in Table 66. 

TABLE 66: Four Outcome Measures for the Value-Based Payment Modifier for Groups of 

Physicians 

NQF 

Numbe

r 

Measure Title Measur

e 

Steward

Domain of 

Care 

N/A 1. Composite of Acute Prevention Quality Indicators N/A Care 

Coordination 

0279 Bacterial Pneumonia 

The number of admissions for bacterial pneumonia per 100,000 population. 

AHRQ 

0281 UTI 

The number of discharges for urinary tract infection per 100,000 population Age 

18 Years and Older in a one year time period 

AHRQ

0280 Dehydration 

The number of admissions for dehydration per 100,000 population. 

AHRQ

N/A 2. Composite of Chronic Prevention Quality Indicators N/A Care 

Coordination

 Diabetes Composite 

0638 Uncontrolled diabetes 

The number of discharges for uncontrolled diabetes per 100,000 population 

AHRQ

 

15 N Engl J Med 2009; 360:1418-1428 
CMS-1590-P 588 

Age 18 Years and Older in a one year time period. 

0272 Short Term Diabetes complications 

The number of discharges for diabetes short-term complications per 100,000 

Age 18 Years and Older population in a one year period.

AHRQ

0274 Long term diabetes complications 

The number of discharges for long-term diabetes complications per 100,000 

population Age 18 Years and in a one year time period. 

AHRQ

0285 Lower extremity amputation for diabetes 

The number of discharges for lower-extremity amputation among patients 

with diabetes per 100,000 population Age 18 Years in a one year time 

period.

AHRQ

0275 COPD 

 The number of admissions for chronic obstructive pulmonary disease 

(COPD) per 100,000 population.

AHRQ 

0277 Heart Failure 

Percent of the population with admissions for CHF.

AHRQ 

N/A 3. All Cause Readmission 

The rate of provider visits within 30 days of discharge from an acute care hospital per 1,000 

discharges among eligible beneficiaries assigned.

CMS Care 

Coordination

N/A 4. 30 Day Post Discharge Visit 

The rate of provider visits within 30 days of discharge from an acute care hospital per 1,000 

discharges among eligible beneficiaries assigned. 

CMS Care 

Coordination

We also note that we are making plans to seek National Quality Forum endorsement for these 

four measures as required by section 1848(p)(2)(B)(ii) of the Act. We seek comment on our 

proposals to use these four measures in the value-based payment modifier for all groups of 

physicians with 25 or more eligible professionals. 

 At this time we are not making proposals regarding how to assess community-level 

performance and how such assessments could be included in the value-based payment modifier 

for groups of physicians. We seek comment, however, on whether measurement and adjustment 

at the community level would further our objectives to encourage and reward physicians and 

groups of physicians for furnishing high-quality, efficient, patient-centered clinical care. 

d. Proposed Cost Measures 

 Section 1848(p)(3) of the Act requires us to evaluate costs, to the extent practicable, 

based on a composite of appropriate measures of costs. In the CY 2012 PFS final rule with 

comment period (76 FR 73434), we finalized use of total per capita cost measures and per capita 

costs measures for beneficiaries with four specific chronic conditions (chronic obstructive 

pulmonary disease, heart failure, coronary artery disease, and diabetes) for the value-based 
CMS-1590-P 589 

payment modifier. Total per capita costs include payments under both Part A and Part B. Total 

per capita costs do not include Medicare payments under Part D for drug expenses. We propose 

to use at least a 60-day run out with a completion factor from our Office of the Actuary (for 

example, claims paid through March 1 of the year following December 31, the close of the 

performance period) to calculate the total per capita cost measures. We seek comment on this 

proposal. 

We used these five measures in the 2010 Physician Feedback reports for individual 

physicians and physician groups; they also will be included in the 2011 Physician Feedback 

reports that we expect to disseminate later in 2012. We propose to continue to use these five 

measures to calculate the cost composite for the value-based payment modifier. We also are 

developing plans to submit these per capita cost measures for National Quality Forum 

endorsement. 

Several recipients of the 2010 Physician Feedback reports objected to being “held 

responsible” for total per capita costs of the beneficiaries that they treated, because they could 

not affect the other costs incurred by the patient. In our view, the total per capita cost measure is 

just one metric used to assess the costs of care. It has no impact until we use it to make 

comparisons among physicians and groups of physicians. In other words, it is not the measure 

itself (because it reflects the total cost of care beneficiaries received), but how we use it to assess 

performance that matters. As described more fully in the composite scoring methodology 

proposals below, we propose to make cost comparisons among groups of physicians using a 

similar beneficiary attribution methodology such that we make “apples to apples” comparisons. 

We believe that this would be an appropriate approach to using the total per capita cost measure 

in the value-based payment modifier. We seek comment on these proposals. 

 (1) Proposed Payment Standardization Methodology for Cost Measures 
CMS-1590-P 590 

Section 1848(p)(3) of the Act requires that “...costs shall be evaluated, to the extent 

practicable, based on a composite of appropriate measures of costs established by the Secretary 

(such as the composite measure under the methodology established under section 

1848(n)(9)(C)(iii)) that eliminate the effect of geographic adjustments in payment rates (as 

described in subsection (e))...” In layman’s terms, this directive requires us to standardize 

Medicare payments to ensure fair comparisons across geographic areas. 

Payment standardization removes local or regional price differences that may cause cost 

variation a physician cannot influence through practicing efficient care. In Medicare, an 

effective payment standardization methodology would exclude Medicare geographic adjustment 

factors such as the geographic practice cost index (GPCI) and the hospital wage index so that, for 

example, per capita costs for beneficiaries in Boston, Massachusetts can be compared to those of 

beneficiaries in Lincoln, Nebraska. Payment standardization, therefore, allows fair comparisons 

of resource use costs for physicians to those of peers who may practice in locations or facilities 

where Medicare payments are higher or lower. 

We have developed a detailed Medicare payment standardization methodology that 

excludes such geographic payment rate differences. We developed the methodology with 

substantial stakeholder input, and we update it annually to incorporate any payment system 

changes. More details of the CMS payment standardization methodology that we are proposing 

can be found at 

http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQne

tTier4&cid=1228772057350. 

We have used this standardization approach, for example, in feedback reports we provide 

to hospitals related to the Medicare Spending per Beneficiary measure. The CMS payment 

standardization methodology includes a number of payment adjustments across the spectrum of 
CMS-1590-P 591 

fee-for-service Medicare. For example, the methodology eliminates adjustments made to 

national payment amounts that reflect PE and regional labor cost differences (measured by the 

GPCI and hospital wage index); substitutes a national amount when services are paid using a 

state fee schedule; eliminates supplemental payments to hospitals that treat a high share of poor 

and uninsured patients (that is, Medicare disproportionate share hospital (DSH) payments) or 

that receive indirect graduate medical education (IME) payments; removes incremental payments 

for community hospitals and Medicare-dependent hospitals above their base payments; and 

eliminates certain rural add-on payments for inpatient psychiatric hospitals and inpatient 

rehabilitation facilities. Outlier payments are treated as they would be if payments were not 

standardized, but they are adjusted to reflect wage differences. 

The CMS payment standardization methodology also eliminates the effect of incentive 

payments under the PFS for physicians that furnish services in rural areas and other underserved 

communities such that they are not disadvantaged in the value-based payment modifier. For 

example, section 1833(m) of the Act provides incentive payments for physicians who furnish 

medical care services in geographic areas that are designated as primary medical care Health 

Professional Shortage Areas (HPSAs) under section 332 (a)(1)(A) of the Public Health Service 

(PHS) Act. The CMS standardization methodology does not include these incentive payments in 

standardized Part B costs so that physicians that furnish services in these areas are not 

disadvantaged in the value-based payment modifier. We believe that by doing so we are 

complying with the requirement in Section 1848(p)(6) to “take into account the special 

circumstances of physicians or groups of physicians in rural areas and other underserved 

communities when applying the value-based payment modifier.” 

We standardized the cost measures in the 2010 Physician Feedback reports to allow fair 

comparisons of costs across physicians. However, we note that the methodology used in the 
CMS-1590-P 592 

2010 Physician Feedback reports differs from the methodology that we are proposing for the 

value-based payment modifier. Although that methodology achieved the same goal of ensuring 

fair comparisons, the standardization techniques used for the 2010 reports were performed at the 

regional level (because the reports focused on providers in four states) and used an averaging 

approach. Thus many of the national adjustments that we have proposed in this rule were not 

applicable to the 2010 Physician Feedback reports. In the 2011 Physician Feedback reports that 

we expect to disseminate later in 2012, we will use the national payment standardization 

methodology currently used to standardize payments in hospital feedback reports for the 

Medicare Spending per Beneficiary measure. We propose to use that same methodology to 

standardize cost measures for purposes of the value-based payment modifier. We believe that 

this approach to payment standardization allows us to standardize payments nationally and to use 

a consistent approach across multiple programs and CMS initiatives. We seek comments on this 

proposal. 

(2) Proposed Risk Adjustment Methodology for Cost Measures 

Section 1848(p)(3) of the Act requires that costs be adjusted to “...take into account risk 

factors[,] such as socioeconomic and demographic characteristics, ethnicity, and health status of 

individuals (such as to recognize that less healthy individuals may require more intensive 

interventions) and other factors determined appropriate by the Secretary.” 

Risk adjustment accounts for differences in patient characteristics not directly related to 

patient care, but that may increase or decrease the costs of care. In the Physician Feedback 

reports, after standardizing per capita costs for geographic factors, we also adjusted them based 

on the unique mix of patients attributed to the physician or group of physicians. Costs for 

beneficiaries with high risk factors (such as a history of chronic diseases, disability, or increased 

age) are adjusted downward, and costs for beneficiaries with low risk factors are adjusted 
CMS-1590-P 593 

upward. Thus, for individual physicians or physician groups who have a higher than average 

proportion of patients with serious medical conditions or other higher-cost risk factors, risk 

adjusted per capita costs are lower than the unadjusted costs, because costs of higher-risk 

patients are adjusted downward. Similarly, for individual physicians or physician groups who 

treated comparatively lower-risk patients, risk adjusted per capita costs were higher than 

unadjusted costs, because costs for lower-risk patients were adjusted upwards. 

In the Physician Feedback program, we applied a risk adjustment methodology to 

account for patient differences in per capita costs that were due to patient demographics such as 

age and gender, socioeconomic factors such as Medicaid dual eligible status, and prior health 

conditions that can affect a beneficiary’s costs, regardless of the efficiency of the care provided. 

This risk adjustment methodology uses the CMS’ Hierarchical Condition Categories (HCC) 

model, which incorporates beneficiary characteristics and prior year diagnoses to predict relative 

Medicare Part A and Part B payments. This model was originally developed under contract to 

CMS by researchers at Boston University and Research Triangle Institute (RTI) with clinical 

input from Harvard Medical School physicians based on an analysis of Medicare FFS 

beneficiaries diagnoses and expenditures. The model is updated every year to incorporate new 

diagnosis codes and is recalibrated regularly to reflect more recent diagnosis and expenditure 

data. 

The HCC model assigns prior year ICD-9-CM diagnosis codes (each with similar disease 

characteristics and costs) to 70 generally high-cost clinical conditions to capture medical 

condition risk. The HCC risk scores also incorporate patient age, gender, reason for Medicare 

eligibility (age or disability), and Medicaid eligibility status, which is in part a proxy for 

socioeconomic status and reflects the greater resources typically used by beneficiaries eligible 

for both Medicare and Medicaid. The risk adjustment model also includes the beneficiary’s end 
CMS-1590-P 594 

stage renal disease (ESRD) status. More information about the risk adjustment model is on the 

CMS Website at http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeedbackProgram/Downloads/122111_Slide_Presentation.pdf. 

We have examined the impacts of applying the above risk adjustment methodology for 

physicians included at the group and individual level in the 2010 Physician Feedback reports and 

believe the approach provides a reasonable method to adjust per capita costs based on 

beneficiary characteristics. The results show that the risk adjustment methodology, in the 

aggregate, compresses the range of per capita costs substantially and that a group of physicians’ 

total per capita cost measures can experience substantial adjustment based upon the risk profile 

of the beneficiary population. For groups of physicians, the risk adjustment methodology had 

the effect of reducing the absolute difference between the groups with the lowest per capita cost 

and the highest total per capita cost by 55.7 percent. In particular, the lowest third of the groups 

were increased by an average of 6.2 percent and the most expensive third were lowered by 10.4 

percent. The middle third, on average, were lowered by 0.1 percent. The range of adjustments 

was between -10.3 percent and +8.2 percent. We found similar results at the individual level. 

We propose to use the same risk adjustment model for risk adjusting total per capita costs 

and the total per capita costs for beneficiaries with four chronic diseases (coronary artery disease, 

COPD, diabetes, and heart failure) as we have used for the group and individual 2010 Physician 

Feedback reports. We seek public comment on applying the same risk adjustment approach to 

the value-based payment modifier as with the Physician Feedback reports. 

(3) Episode-based Cost Measures 

 Section 1848(n)(9)(A)(ii) of the Act as added by section 3003 of the Affordable Care 

Act, required CMS to develop a Medicare episode grouper by January 1, 2012. Four contractors 

submitted prototype episode groupers to CMS in September 2011, and, after evaluating the 
CMS-1590-P 595 

prototypes, we selected one to develop its prototype episode grouper into a comprehensive 

Medicare episode grouper. This process will entail additional technical and analytical 

development, as well as testing of the more fully developed episode grouping product. Initially 

the episode grouper will focus on selected chronic conditions and acute events. As development 

of the selected episode grouper continues, we expect to see the number of conditions increase. 

We plan to use the episode grouper in future Physician Feedback reports in order to test and gain 

stakeholder input into the development of the episodes of care. 

 Although the statute does not require the use of the episode-based cost measures for the 

value-based payment modifier, it requires that we use such cost measures in the Physician 

Feedback reports. We plan to include episode-based cost measures for several conditions in the 

Physician Feedback reports beginning in 2013 (based on 2012 data). Interested parties that 

commented on the CY 2012 PFS final rule with comment period (76 FR 73434) recommended 

that we use episode-based cost measures in the value-based payment modifier, rather than total 

per capita costs, because episode-based costs are used in many private sector pay-forperformance programs and directly reflect care provided by physicians. We anticipate providing 

episode-based cost measures in the Physician Feedback reports before proposing them for the 

value-based payment modifier in future rulemaking. 

e. Attribution of Quality and Cost Measures 

Calculation of administrative claims-based quality and cost measure performance rates 

requires us to attribute Medicare beneficiaries to groups of physicians. For example, for the 

PQRS administrative claims-based reporting option, we must attribute beneficiaries to groups of 

physicians (as identified by a single TIN) so that we are able to calculate the relevant quality 

measure and cost measure performance rates. Likewise, we must attribute beneficiaries to 

groups of physicians that submit data on quality measures under the PQRS GPRO in order to 
CMS-1590-P 596 

calculate the cost measure performance rates. In the 2010 Physician Feedback reports, we used 

two different attribution methodologies: one method for individual physicians (“degree of 

involvement method”) and another method for groups of physicians (“plurality of care method”). 

This section discusses our proposals for using these attribution methods to calculate the quality 

and cost measures for the value-based payment modifier. We note that the attribution methods 

do not impact beneficiaries’ choice of providers. 

We used the plurality of care method to attribute beneficiaries in the 2010 Physician 

Feedback reports provided to the group practices using the PQRS GPRO web-interface. In this 

method, we attributed Medicare FFS beneficiaries to the group practice that billed a larger share 

of office and other outpatient Evaluation and Management (E/M) services (based on dollars) than 

any other group of physician practice (that is, the plurality). In addition, beneficiaries had to 

have at least two E/M services at the group of physicians. We used this attributed population to 

identify a sample of beneficiaries eligible for the quality measures reported via the PQRS GPRO 

web-interface. We also calculated the per capita cost measures based on this attributed 

population. 

In the discussion above regarding beneficiary attribution for groups of physicians 

choosing to report quality measures through the PQRS GPRO web-interface, we are seeking 

comment on the continued use of the “plurality of care” attribution methodology or to use the 

Medicare Shared Savings Program attribution methodology for 2013 and beyond. The Medicare 

Shared Savings Program attribution methodology is described at 

http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/sharedsavingsprogram/Statutes_Regulations_Guidance.html. For purposes of program 

alignment, we propose to use the same attribution methodology that we finalize for the PQRS 

GPRO web-interface to attribute beneficiaries to groups of physicians for purposes of the value-
CMS-1590-P 597 

based payment modifier. This proposal means that we would calculate the per capita cost 

measures based on the same attributed beneficiary population as we use for determining the 

quality measures for the group of physicians that report PQRS quality data through: PQRS 

GPRO using the web-interface, claims, registries, or EHRs; or PQRS administrative claimsbased option. 

We are concerned, however, that such an attribution methodology may be too restrictive 

because it relies solely on office (E/M) visit codes and it could fail to attribute beneficiaries 

whom the group practices would identify as their beneficiaries. This situation may occur, for 

example, with single specialty groups such as radiologists or anesthesiologists that do not submit 

claims that use E/M codes. For these reasons, we seek comment on whether to use an alternative 

approach (such as the “degree of involvement” method that is discussed next) for all groups of 

physicians except those reporting quality measures using the PQRS GPRO web-interface. 

We used the “degree of involvement” method to attribute beneficiaries for cost purposes 

to individual physicians in the CY 2010 Physician Feedback reports, which we produced for 

physicians (23,730 physicians in total) in four states: Iowa; Kansas; Missouri; and Nebraska. 

Under this attribution method, we classified the patients for which a physician submitted at least 

one Medicare FFS Part B claim into three categories (directed, influenced, and contributed) 

based on the amount of physician involvement with the patient:16

● For directed patients, the physician billed for 35 percent or more of the patient’s office 

or other outpatient evaluation and management (E&M) visits. 

● For influenced patients, the physician billed for fewer than 35 percent of the patient’s 

outpatient E&M visits but for 20 percent or more of the patient’s total professional costs. 

● For contributed patients, the physician billed for fewer than 35 percent of the patient’s 

 

16 CMS, “Detailed Methodology for Individual Physician Reports” (2012), available at 

http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeedbackProgram/Downloads/QRURs_for_Individual_Physicians.pdf 
CMS-1590-P 598 

outpatient E&M visits and for less than 20 percent of the patient’s total professional costs. 

The result of this methodology is that all of the beneficiaries for which a physician 

submitted Medicare Part B claims are attributed to the physician, but the beneficiaries are 

classified according to the degree of physician involvement with the beneficiary. We then 

calculated per capita cost measures for the beneficiaries within each of these three classifications. 

In addition, a beneficiary can be attributed to more than one physician (and in different 

categories) if the beneficiary received services from more than one physician. 

 Based on the CY 2010 reports, physicians that “directed” care billed, on average, 

approximately three E/M visits with the patient, which represented over 64 percent of all E/M 

services furnished by the physicians treating the beneficiary. Although the directed attribution 

rule permits two physicians to be attributed to the same beneficiary (because only two physicians 

could each have greater than 35 percent of the beneficiaries E/M visits), in practice that rarely 

happened as a physician that directed care of a beneficiary had the substantial majority of E/M 

visits, that accounted for 31 percent of costs among all physicians treating the beneficiary. These 

observations indicate the physician had substantial control over the patient’s care. In addition to 

primary care specialties, the other specialties with the greatest percentage of physicians directing 

care were rheumatology and oncology. 

Physicians that “influenced” care had, on average, one E/M visit with the beneficiary, but 

also had slightly over one-third of the beneficiaries’ total Part B costs. Although the average 

number of E/M visits was low, the physician, on average, billed for one procedure during the 

year and this procedure was the most expensive one for the patient. This share of Part B costs 

was greater than physicians that directed or contributed to a beneficiary’s care. Although the 

influenced attribution rule permits up to five physicians to influence care (because five 

physicians could each bill 20 percent of total Part B costs), this rarely happened as a physician 
CMS-1590-P 599 

that influenced care of a beneficiary had, on average, approximately 84 percent of total Part B 

costs compared to other physicians that could have influenced care. Medical specialists and 

surgeons, including ophthalmology, orthopedic surgery, plastic and reconstructive surgery had 

the greatest percent of beneficiaries for which they influenced care. 

Physicians that “contributed” to care had, on average, less than one E/M visit per year 

with the beneficiary and billed for less than, on average, 20 percent of average beneficiaries’ 

total professional costs, thus indicating that the beneficiary received care from many providers. 

On average, at least five physicians contributed to a beneficiary’s care (not including those that 

directed or influenced that care). 

 We calculated average total per capita cost measures for physicians by attribution rule 

and these costs are shown in Table 67. Not surprisingly, total per capita costs for directed and 

influenced beneficiaries were about 50 percent of the total per capita costs of physicians with 

contributed beneficiaries. The costs in Table 67 show that beneficiaries that receive care from 

multiple physicians, have substantially higher per capita costs. In addition, approximately 20 

percent of Medicare beneficiaries covered by the 2010 Physician Feedback reports had 

contributed care in which physicians only contributed to it. In other words, the care furnished 

was neither “directed” nor “influenced” by a physician. 

TABLE 67: Average Per Capita Costs by Attribution Rule for Physicians in Iowa, Kansas, 

Nebraska, and Missouri 

Attribution Rule Average Total Per Capita Cost 

All physicians $18,831 

Physicians with Directed Beneficiaries $10,719 

Physicians with Influenced Beneficiaries $9,407 

Physicians with Contributed Beneficiaries $20,243 

 We believe the value-based payment modifier should address not only the care for 
CMS-1590-P 600 

beneficiaries that a physician may “direct” or “influence,” but also play a role in encouraging 

more efficient, not just more, care for beneficiaries. We believe that any attribution rule should 

consider the “contributed” beneficiaries, especially those beneficiaries that are neither directed 

nor influenced by other physicians, because the care of these beneficiaries is where the greatest 

potential for improved care and coordination reside. 

 As explained more below, we seek comment on whether to attribute two populations of 

beneficiaries to groups of physicians using (1) a combination of the directed and influenced rules 

and (2) the contributed rule. If we were to finalize this attribution methodology, we would 

calculate a separate per capita cost measures for each patient population. For example, we would 

calculate one total per capita cost measure for the groups of physicians’ “directed and 

influenced” beneficiaries and a second total per capita cost measure for the groups’ “contributed” 

beneficiaries. (In the value-based payment modifier scoring methodology section below, we 

explain our proposals for how to score and weight these measures to ensure fair comparisons 

among groups of physicians). 

 First, we would attribute beneficiaries to a group of physicians that billed for 35 percent 

or more of the patient’s office or other outpatient (E/M) visits or at least 20 percent or more of 

the beneficiary’s total professional costs. This proposal combines the “directed” and 

“influenced” methods discussed above. Combining “directed” and “influenced” beneficiaries 

into one attributed patient population is reasonable because groups of physicians that care for 

these beneficiaries treat them, on average, more than any other physician or are responsible for a 

large percentage of professional costs. Combining the “directed” and “influenced” rules 

attributes beneficiaries to the group of physicians over which they have substantial control of 

resource utilization. 
CMS-1590-P 601 

Second, we would attribute a second and separate patient population to the group of 

physicians which would consist of the remaining beneficiaries to whom a group of physicians 

provided service but who were not attributed in the first patient population (for example, 

beneficiaries for which the group of physicians did not bill for 35 percent of more of E/M visits 

and for less than 20 percent of professional costs). This rule corresponds to the “contributed” 

category discussed above. We believe that attributing a second patient population to groups of 

physicians ensures accountability for all beneficiaries to whom a group of physicians furnishes 

services. We seek comment on whether to use the “degree of involvement” attribution method 

for all groups of physicians that submit data on PQRS quality measures through PQRS GPRO 

using claims, registries, and EHRs, and through the PQRS administrative claims-based option. 

f. Proposed Composite Scores for the Value-Based Payment Modifier 

 Section 1848(p)(2) of the Act requires that quality of care be evaluated, to the extent 

practicable, based on a composite of measures of the quality of care furnished. Likewise, section 

1848(p)(3) of the Act requires that cost measures used in the value-based payment modifier be 

evaluated, to the extent practicable, based on a composite of appropriate measures of costs. This 

section discusses our proposals for constructing the quality of care and cost composites. 

(1) Proposed Quality of Care and Cost Domains 

 In many of our value-based purchasing programs such as Hospital Value-Based 

Purchasing and the Medicare Shared Savings Program, we selected and classified measures into 

quality domains that reflect important national objectives for quality assessment and 

improvement. We believe it is important to align the quality measures used in the value-based 

payment modifier with the national priorities established in the National Quality Strategy. The 

National Quality Strategy outlined six priorities including: 

● Make care safer by reducing harm caused in the delivery of care (patient safety). 
CMS-1590-P 602 

● Ensure that care engages each person and family as partners (patient experience). 

● Promote effective communication and coordination of care (care coordination). 

● Promote the most effective prevention and treatment practices for leading causes of 

mortality (clinical care). 

● Work with communities to promote wide use of best practice to enable healthy living 

(population/community health). 

● Make quality care more affordable for individuals, families, employers, and 

governments by developing and spreading new health care delivery models (efficiency).17

We propose to classify each of the quality measures that we proposed for the value-based 

payment modifier into one of these six domains. We propose to weight each domain equally to 

form a quality of care composite. We believe this is a straightforward approach that recognizes 

the importance of each domain. Within each domain, we propose to weight each measure 

equally so that groups of physicians have equal incentives to improve care delivery on all 

measures. To the extent that a domain does not contain quality measures, the remaining domains 

would be equally weighted to form the quality of care composite. For example, if three domains 

contain quality information, each domain would be weighted at 33.3 percent to form the quality 

composite. 

In terms of the cost composite, we finalized in the CY 2012 PFS final rule (76 FR 73434) 

total per capita costs (Parts A and B) and total per capita costs for beneficiaries with four chronic 

diseases (diabetes, CAD, COPD, heart failure). We propose to group these five per capita cost 

measures into two separate domains: total overall cost (one measure) and total costs for 

beneficiaries with specific conditions (four measures). A separate domain for costs for 

beneficiaries with specific conditions highlights our desire to incentivize efficient care for 

 

17 National Quality Strategy, http://www.healthcare.gov/law/resources/reports/nationalqualitystrategy032011.pdf. 
CMS-1590-P 603 

beneficiaries with these conditions. 

Similar to the quality of care composite, we propose to weight each cost domain equally 

to form the cost composite and within the cost domains we propose to weight each measure 

equally. In those instances in which we cannot calculate a particular cost measure, for example 

due to too few cases, we propose to weight the remaining cost measures in the domain equally. 

 If we were to attribute two patient populations to each group of physicians as discussed 

above regarding the “degree of involvement” attribution methodology, we propose to weight the 

measures in each population based on the group of physicians’ allowed charges for beneficiaries 

attributed to each population so that the cost composite accurately reflects the cost of care 

furnished. We seek comment on these proposals. Table 68 graphically depicts these proposals 

for the quality of care and cost composites and how they relate to the value-based payment 

modifier. 
CMS-1590-P 604 

TABLE 68: Relationship between Quality of Care and Cost Composites and the ValueBased Payment Modifier 

(2) Proposed Value-Based Payment Modifier Scoring Methods 

 We adopted different methods to score quality and cost measures in our value-based 

purchasing programs with each scoring methodology tailored to further the program’s purpose. 

For example, in the Medicare Shared Savings Program, we finalized a point system scoring 

methodology that assesses performance against established Medicare program benchmarks for 

each quality measure. In the hospital-value based purchasing program, we used a point system 

methodology that considered both a hospital’s achievement and improvement from a baseline 

performance period. We then translated these points using a linear exchange function to develop 

a unique payment modifier for each hospital. 

For the value-based payment modifier, we believe the composite scoring methodology 

Quality of Care 

Composite 

Clinical care 

Patient experience 

VALUE 

MODIFIER 

SCORE 

Cost 

Composite 

Total costs for beneficiaries 

with specific conditions 

Population/Community 

Health 

Patient safety 

Efficiency 

Total overall costs 

Care coordination 
CMS-1590-P 605 

should keep intact the underlying distribution of performance rates so that the composite scores 

distinguish clearly between high and low performance. Groups of physicians also should easily 

be able to understand how performance on a quality or cost measure can affect their composite 

score, and hence their payment. We also believe that the composite scoring methodology should 

be used at all performance assessment levels (individual physician, group of physicians, 

hospital). Thus, because we are proposing to provide flexibility to groups of physicians as to the 

quality measures they report, the scoring methodology needs to be able to compare “apples to 

apples.” 

Therefore, we propose a scoring approach that focuses on how the group of physicians’ 

performance differs from the benchmark on a measure-by-measure basis. For each quality and 

cost measure, we propose to divide the difference between a group of physicians’ performance 

rate and the benchmark by the measure’s standard deviation. The benchmarks, as further 

described below, are the national means of the quality or cost measure. This step produces a 

score for each measure that is expressed in standardized units. As discussed above, we propose 

to weight each measure’s standardized score equally with other measures in the domain to obtain 

the domain standardized score. We propose to weight the domain scores equally to form the 

quality of care and cost composites. We seek comment on this proposal. 

We believe that this proposal achieves our policy objective to distinguish clearly between 

high and low performance and to allow us to create composites of quality of care for groups of 

physicians that report different quality measures. We also note that this approach is used in 

several private sector physician profiling efforts.18

Table 69 illustrates how we would score three hypothetical quality measures in the same 

quality domain under our proposal. A standardized score of zero means that performance is at 

 

18 See e.g., Tufts Health Plan, “How Does Tufts Health Plan Tier Its Doctors” available at 

http://www.tuftshealthplan.com/members/members.php?sec=how_your_plan_works&content=your_choice&rightna

v=your_choice_nav&WT.mc_id=members_leftnav_hypw_yourchoice&WT.mc_ev=click 
CMS-1590-P 606 

the national mean. Higher standardized scores (for example, 2.98) mean that performance is 

better than the national mean. Likewise, a large negative score means that performance is much 

lower than the national mean. In the example shown in Table 69, the quality domain score 

would be 0.79 (the average of the three quality measures’ standardized units) meaning the group 

of physicians scored slightly better than average in this quality domain. We would use the same 

method for the quality measures in the other domains that a group of physicians reported. 

TABLE 69: Example of Standardized Scores in one Quality Domain 

 Group of 

Physicians’ 

Performance 

Rate 

Benchmark 

(National 

Mean) 

Standard 

Deviation 

Standardized 

Unit 

Quality Measures 

Measure 1 95.0 93.5 3.3 0.47 

Measure 2 71.4 86.3 13.9 -1.07 

Measure 3 100.0 60.6 13.2 2.98 

Quality Domain Score 0.79 

 

(3) Proposed Benchmarks and Peer Groups for Quality Measures 

We propose that the benchmark for each quality measure be the national mean of each 

measure’s performance rate during the performance period. We propose to unify the calculation 

of the benchmark by weighting the performance rate of each physician and group of physicians 

submitting data on the quality measure by the number of cases used to calculate the performance 

rate. Alternatively, we could weight each quality measure reported by groups of physicians by 

the number of physicians in the group. We seek not to bias how physicians choose to report 

quality measures (that is, at the group or individual level) by establishing different benchmarks 

for the same quality measures. Moreover, we believe beneficiaries are entitled to high quality 

care, regardless of whether a group of physicians or an individual physician furnishes it. 

In addition, we propose that the benchmarks for quality measures in the PQRS 
CMS-1590-P 607 

administrative claims-based reporting option be the national mean of each quality measure’s 

performance rate calculated at the TIN level. We propose to calculate the national mean by 

including the all TINs of groups of physicians with 25 or more eligible professionals. We 

propose to weight the TIN’s performance rate by the number of cases used to calculate the 

quality measure. 

To help groups of physicians understand how their quality measure performance affects 

their quality of care composite score, we propose to publish the previous years’ performance 

rates (and standardized scores) on each quality measure. By doing so, groups of physicians will 

be better informed on how their performance may affect their payment in the coming year. We 

note, for example, that “topped out” quality measures are unlikely to have significantly higher or 

lower standardized scores for each measure because performance is clustered around the mean, 

and this scoring method seeks to differentiate performance from the mean. We seek comment on 

these proposals. 

(4) Proposed Benchmarks and Peer Groups for Cost Measures 

To ensure fair cost comparisons that identify groups of physicians that are outliers (both 

high and low), we believe the same methodology should be used to attribute beneficiaries to the 

groups of physicians and to the groups of physicians in the peer group. We seek to compare like 

groups of physicians that use the same cost attribution methodology to ensure we are making 

“apples to apples” comparisons among groups of physicians. As discussed above, there are two 

ways to attribute beneficiaries to groups of physicians (“plurality of care” and “degree of 

involvement”). We have proposed to use the “plurality of care” method for groups of 

physicians, regardless of whether they report data on PQRS quality measures using the GPRO 

web-interface, claims, registries, or EHRs; or the PQRS administrative claims-based option. 
CMS-1590-P 608 

Thus, we propose that the peer group for the cost measures include all other groups of physicians 

for which we use the “plurality of care” to attribute beneficiaries. 

We seek comment on how the cost measure peer groups would change if we adopt the 

“degree of involvement” methodology for groups of physicians other than groups of physicians 

using the PQRS GPRO web-interface to submit data on quality measures. 

Alternatively, we seek comment on establishing cost benchmarks on a quality measureby-quality measure basis. Under this alternative approach, we would set the benchmark as the 

mean per capita cost of the physicians or groups of physicians that reported the quality measure – 

whether it was reported by a group of physicians or at the individual physician level. This 

approach encourages groups of physicians to select to report quality measures that reflect their 

practice patterns and patient populations more accurately. We seek comment on whether we 

should adopt this approach. 

We also note that although we are not proposing in this rule to use episode-based costs, 

the scoring methodology that we have proposed can readily be used to identify high and low 

performers relative to a national benchmark for episodes of care. For example, we could develop 

an episode cost profile for a typical beneficiary with macular degeneration. We could then use 

the proposed scoring methodology to identify groups of physicians that have high and low 

episode costs relative to the benchmark. In addition, if we were to use such episode-based cost 

measures, we could use attribution methods that seek to stratify beneficiaries by relevant 

condition-specific characteristics to ensure fair and accurate peer group comparisons among 

physicians. We seek comment on our plans to use this approach in the future. 

(5) Proposed Reliability Standard 

 We believe it is crucial that the value-based payment modifier be based on quality of care 

and cost composites that reliably measure performance. Statistical reliability depends on 
CMS-1590-P 609 

performance variation for a measure across physicians (“signal”), the random variation in 

performance for a measure within a physician’s payment of attributed beneficiaries (“noise”), 

and the number of beneficiaries attributed to the physician. In other words, reliability is defined 

as the extent to which variation in the measure’s performance rate is due to variation in the 

quality (or cost) furnished by the physicians (or group of physicians) rather than random 

variation due to the sample of cases observed. Reliability is important so that we can confidently 

distinguish the performance of one physician (or group of physicians) from another.19 Potential 

reliability values range from zero to one, where one (highest possible reliability) signifies that all 

variation in the measure’s rates is the result of variation in differences in performance across 

physicians (or groups of physicians). Generally, reliabilities in the 0.40-0.70 range are often 

considered moderate and values greater than 0.70 high. 

 Therefore, we propose to establish a minimum number of cases in order for a quality or 

cost measure to be included in the quality of care or cost composite. To the extent that a group 

of physicians fails to meet the minimum number of cases for a particular measure, the measure 

would not be counted and the remaining measures in the domain would be given equal weight. 

To the extent that we cannot develop either a reliable quality of care composite or cost composite 

because we do not have reliable domain information, we would not calculate a value-based 

payment modifier and payment would not be affected. We recognize that a trade-off exists 

between developing a program that will eventually cover all physicians and groups of physicians 

and providing statistically reliable performance results. In this instance, as we increase the 

reliability threshold by requiring a higher minimum case size threshold, the number of physicians 

and groups of physicians for which we can develop a reliable quality of care or cost composite 

decreases. Based on an analysis of the individual CY 2010 Physician Feedback reports and on 

 

19 John L. Adams, “The Reliability of Provider Profiling, A Tutorial,” Rand Corporation (2009). 
CMS-1590-P 610 

recent literature, we propose a minimum case size of 20 for both quality and cost measures to 

ensure high statistical reliability.20 This proposal means that if a group of physicians does not 

have 20 or more beneficiaries eligible for a particular measure, that particular measure would not 

be included in the calculation of the value-based payment modifier. 

 Our reliability analysis of the quality and cost measures in the 2010 individual Physician 

Feedback reports informs our minimum case size proposal. The average reliability of the total 

per capita cost measure assessed at the individual level for physicians in all specialties was high 

(greater than .70) when the minimum case size was 20 or more. There was a slight increase in 

average reliability by increasing minimum case size to 30 cases. Increasing the minimum case 

size from 20 to 30, however, decreases the number of physicians for which we can calculate a 

reliable cost measure for physicians. The decrease in the number of physicians is small for some 

specialties (for example, internal medicine, family practice) but is much greater for other 

specialties (for example, thoracic surgery, allergy/immunology). 

 Reliability was high for nine of the 15 administrative claims based quality measures that 

we are proposing for purposes of the value-based payment modifier for the PQRS administrative 

claims-based reporting option when the minimum case size was 20 or greater. Average 

reliability increases slightly by increasing case size to 30, but the number of physicians 

decreases, on average, by 30 percent of eligible physicians. We anticipate that statistical 

reliability of the quality and cost measures will increase when we assess physicians at the TIN 

level rather than NPI level, because, on average, a TIN will be attributed more beneficiaries than 

an NPI. We seek comment on these proposals. 

g. Proposed Payment Adjustment Amount 

 

20 Robert L. Houchens, “The Reliability of Physician Cost Profiling in Medicare,” (Aug. 2010) (Describing how for 

most physician specialties, Medicare physician cost profile scores are substantially more reliability than those 

derived from commercial settings,) 
CMS-1590-P 611 

 Section 1848(p) of the Act does not specify the amount of physician payment that should 

be subject to the adjustment for the value-based payment modifier; however, section 

1848(p)(4)(C) of the Act requires the payment modifier be implemented in a budget neutral 

manner. Budget neutrality means that payments will increase for some groups of physicians due 

to high performance and decrease for others due to low performance, but the aggregate amount 

of Medicare spending in any given year for physicians’ services will not change as a result of 

application of the value-based payment modifier. 

 In making proposals about the amount of Medicare payment made under the PFS at risk 

for the value-based payment modifier, we considered that there are two other payment 

adjustments affecting physicians’ Medicare payment in 2015 that could further decrease 

physician payments in 2016. Specifically, under PQRS, a physician who does not satisfactorily 

submit data on quality measures during the applicable reporting period in 2013 have their fee 

schedule amount reduced by 1.5 percent for service furnished in 2015. This PQRS downward 

payment adjustment to the fee schedule will increase to 2 percent in 2016 (and thereafter) based 

on reporting periods that fall in CY 2014 (and thereafter, reporting period or periods that fall two 

years prior to the year in which the PQRS payment adjustment is assessed). However, as noted 

previously in this preamble, individual physicians and groups of physicians that satisfactorily 

submit data on PQRS quality measures via any of the reporting methods proposed for the 2015 

and 2016 PQRS payment adjustment would avoid the PQRS downward payment adjustment. 

The second payment adjustment is for physicians that are not meaningful EHR users. Section 

1848(a)(7) of the Act provides for a downward payment adjustment of 1 percent in 2015 (based 

on performance in 2013), 2 percent in 2016 (performance in 2014), and 3 percent in 2017 

(performance in 2015). We note that the adjustment in 2015 for not being a meaningful EHR 
CMS-1590-P 612 

user is increased by 1 percentage point (to -2 percent) if the physician was subject to the eRx 

Incentive Program payment adjustment for 2014. 

To balance our goals of beginning the implementation of the value modifier consistent 

with the legislative requirements and to give us and the physician community experience in its 

operation, we propose to separate groups of physicians with 25 or more eligible professionals 

into two categories. 

 For those groups of physicians that have met the criteria for satisfactory reporting 

established for the value-based payment modifier and request that their value-based payment 

modifier be calculated using a quality-tiering approach, we propose that the maximum payment 

adjustment be -1.0 percent for poor performance (Table 70 displays the different downward 

payment adjustments depending upon a group of physicians’ quality and cost tiers). We 

recognize that 2015 is the initial year for the value-based modifier and, thus, we are providing for 

a very modest adjustment for the program’s initial years. A payment adjustment of -1.0 percent 

means that groups of physicians would receive 99.0 percent of the PFS payment amount for the 

service involved. Due to the BN requirement, we are not proposing the exact amount of the 

upward payment adjustments for high performance under the value-based payment modifier 

because the upward payment adjustments (in the aggregate) will have to balance the downward 

payment adjustments in order to achieve BN. Thus, we propose to determine the projected 

aggregate amount of downward payment adjustments and then calculate the upward payment 

adjustment factor based on the amount of the projected aggregate upward payment adjustments. 

Our proposals regarding the payment modifier scoring models in the next section explain how 

we proposed to calculate upward adjustments for high performance. 

For groups of physicians with 25 or more eligible professional that have not met the 

criteria for satisfactory reporting established for the value-based payment modifier (including 
CMS-1590-P 613 

those groups that have not participated in any of the PQRS reporting mechanisms), we propose 

to set their value-based payment modifier at -1.0 percent. We arrived at our proposal for a -1.0 

percent downward adjustment using the following rationale. Section 1848(p) of the Act requires 

us to differentiate payment based on a comparison of quality of care furnished compared to cost. 

Because we do not have performance rates on which to assess the quality of care furnished by 

these groups, we can differentiate payment based on costs only. A cost-only comparison would 

set a lower downward adjustment for low-cost groups than for high-cost groups. Due to the fact 

that the value-based payment modifier is just starting in 2015, we do not wish to apply a greater 

downward payment adjustment for non-satisfactory reporters than we are proposing for the low 

quality/high cost groups that request that their value-based payment modifier be calculated using 

a quality-tiering approach. Thus, we propose to equalize the downward payment adjustment 

across these groups of physicians, despite the fact that they may have different costs. We seek 

comment on this approach. 

h. Proposed Value-Based Payment Modifier Scoring Methodology 

 Section 1848(p)(1) of the Act requires the Secretary to establish a payment modifier that 

provides for differential payment to a physician or group of physicians under the fee schedule 

based upon the quality of care furnished compared to cost during a performance period. As 

noted previously, the statute requires that quality of care furnished and cost shall be evaluated, to 

the extent practicable, based on composites of quality of care furnished and cost. This section 

discusses our proposals for comparing the quality of care furnished to cost for those groups of 

physicians that request their value-based payment modifier be calculated using a quality-tiering 

approach. 

 In making our proposals, we developed two models that compare the quality of care 

furnished to costs: a quality tier model and a total performance score model. We propose the 
CMS-1590-P 614 

quality-tiering model for the value-based payment modifier, but we seek comment on the total 

performance score model. We also note that the literature on physician pay-for-performance 

includes other models, such as one based on an efficient frontier, that we are not proposing 

here.21 We seek comment on these proposals. 

(1) Quality-Tiering Model 

 The quality-tiering model compares the quality of care composite with the cost composite 

to determine the value-based payment modifier. To make this comparison, we propose to 

classify the quality of care composites scores into high, average, and low quality of care 

categories based on whether they are statistically above, not different from, or below the mean 

quality composite score. We seek to ensure that those groups of physicians classified as high or 

low performers have performance that is meaningfully different from average performance (to be 

sure that no group of physicians is disadvantaged for performance only slightly different from 

the benchmark) and is precisely measured (to ensure that no group of physicians is 

disadvantaged by an inaccurate performance assessment). We propose to assess meaningful 

differences as those performance scores that are at least one standard deviation from the mean. 

We propose to assess precision by requiring a group of physicians’ score to be statistically 

different from the mean at the 5.0 percent level of significance. We seek comment on these 

proposals and on whether we should only examine meaningful differences that are at least two or 

three standard deviations away from the mean. We also seek comment on whether to define the 

high and low categories of the quality composites as a fixed percentage (for example, 2.5 

percent) of the number of groups of physicians or of the amount of payments under the PFS. 

Such an approach would minimize the number of group of physicians subject to payment 

adjustments. 

 

21 David Knutson, et al, “Alternative Approaches to Measuring Physician Resource Use,” Second Interim Report 

(Dec. 2010), available at http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-andReports/Reports/downloads/Knutson_MN_2nd_InterimReport_AltApproaches_2010.pdf 
CMS-1590-P 615 

 Likewise, we propose to identify those groups of physicians that have cost composite 

scores that are statistically different from the mean cost composite score of all groups of 

physicians. We propose to classify these groups of physicians into high, average, and low cost 

categories based on whether they are significantly above, not different from, or below the mean 

cost composite score as described above with reference to quality composite. We propose to 

assess meaningful differences as those performance scores that are at least one standard 

deviation from the mean and we propose to assess precision at the 5.0 percent level of 

significance. We seek comment on these proposals and on whether we should only examine 

meaningful differences that are at least two or three standard deviations away from the mean. 

We also seek comment on whether to define the high and low categories of the cost composites 

as a fixed percentage (for example, 2.5 percent) of the number of groups of physicians or of the 

amount of payments under the PFS. 

We propose to compare quality of care composite classification with the cost composite 

classification to determine the value-based payment modifier adjustment according to the 

amounts in Table 70. 

TABLE 70: Value-Based Payment Modifier Amounts for the Quality-Tiering Approach 

Quality/cost Low cost Average cost High cost 

High quality +2.0x* +1.0x* +0.0% 

Average quality +1.0x* +0.0% -0.5% 

Low quality +0.0% -0.5% -1.0% 

* Groups of physicians eligible for an additional +1.0x if reporting measures and average 

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

We propose to establish the upward payment adjustment factor (“x”) after the 

performance period has ended based on the aggregate amount of downward payment 

adjustments. We also propose to aggregate the downward payment adjustments in Table 70 with 

the downward adjustment for groups of physicians with 25 or more eligible professionals first 
CMS-1590-P 616 

and then to solve for the upward payment adjustment factor (“x”). For example, after 

determining the aggregate projected amount of the downward payment adjustments, CMS could 

calculate that the payment adjustment factor (“x”) would be 0.75 percent such that high 

quality/low cost groups of physicians would receive a 1.5 percent (2 x 0.75) upward payment 

adjustment during the payment adjustment period. 

We also propose an additional incentive for groups of physicians to furnish care to highrisk Medicare beneficiaries. We seek to ensure that the value-based payment modifier does not 

cause unintended consequences in which groups of physicians decline to treat the most difficult 

cases. In particular, we propose that the scoring methodology provide a greater upward payment 

adjustment (+1.0x) for groups of physicians that care for high-risk patients (as evidenced by the 

average HCC risk score of the attributed beneficiary population) and submit data on PQRS 

quality measures through PQRS via the GPRO using the web-interface, claims, registries, or 

EHRs. We propose to increase the upward payment adjustment to +3x (rather than +2x) for 

groups of physicians classified as high quality/low cost and to +2x (rather than +1x) for groups 

of physicians that are either high quality/average cost or average quality/low cost if the group of 

physicians’ attributed patient population has an average risk score that is in the top 25 percent of 

all beneficiary risk scores. In other words, we are not proposing this additional upward payment 

adjustment (+1.0x) for groups of physicians that select the PQRS administrative claims-based 

reporting option. 

We propose this quality-tiering scoring methodology because it compares the quality of 

care furnished to cost as required by the statute. It also allows physicians to understand clearly 

how their payment is affected by their scores on the quality of care and cost composites. We 

also believe it is a reasonable way to start to modify physician payment because it clearly 

distinguishes the outliers (for example, high quality/low cost compared to low quality/high cost) 
CMS-1590-P 617 

from mean performance. The framework also allows us to fine tune payment adjustments as we 

gain greater experience with the proposed methodologies. 

We seek comment on this proposal and on the proposed scoring methodologies. We seek 

comment in particular on whether it is appropriate to apply the same upward payment adjustment 

in Table 70 to groups of physicians classified as high quality/medium cost and medium 

quality/low cost. In addition, we seek comment on whether we should not provide as great an 

upward payment adjustment for those groups of physicians that select to report under the PQRS 

via the administrative claims-based reporting option, so that we encourage greater PQRS 

participation. 

 (2) Total Performance Score 

 A second approach to scoring the value-based payment modifier is a total performance 

score approach. This approach allows us to develop a unique value-based payment modifier for 

each group of physicians. This approach results in a range of continuous payment adjustments 

rather than the thresholds proposed in the quality tier approach. Under this approach, we could 

calculate a total performance score (TPS) by equally weighting the quality of care and cost 

composites. A negative score for the quality composite (Physician Group 2 in Table 71) means 

the group of physicians performed below the national average on the relevant quality measures. 

Likewise, a negative score for the cost composite means the group of physicians had higher costs 

than the national average. A score of zero means that the group of physicians performed at the 

national average. The example in Table 71 illustrates how we could calculate the TPS for three 

groups of physicians. In this example, Physician Groups 1 and 3 are above average and 

Physician Group 2 is below average. 

TABLE 71: Example of Total Performance Score 

Quality Composite 

(50%) 

Cost Composite 

(50%) TPS 
CMS-1590-P 618 

 Physician Group 1 .9 .2 .55 

 Physician Group 2 -.9 -1.2 -1.05 

 Physician Group 3 2.2 1.2 1.70 

 We could develop an exchange function in which we translated the TPS into a unique 

value-based payment modifier for each group of physicians. This method would be similar to 

the approach we use in the Hospital Value-Based Purchasing program where we use a linear 

exchange function to develop a unique payment for each hospital. This approach results in a 

continuous array of unique value-based payment modifiers such that there are no longer cut-off 

points between high and low performing groups of physicians. Rather, each group of physicians’ 

payment would be modified under this approach. 

 We believe the quality-tiering approach may better compare the quality of care furnished 

to costs. We also believe that the quality-tiering approach is more transparent because groups of 

physicians may be more aware of the level at which quality and cost performance is likely to 

result in payment adjustment. However, we seek comment on these observations and whether to 

use the total performance score methodology rather than the quality-tiering methodology for the 

value-based payment modifier. If we were to use a total performance score methodology, we 

also seek comment on the weights to be given to quality and cost composites. 

i. Proposed Informal Review and Inquiry Process 

 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 value-based payment modifier; 

● The evaluation of the quality of care composite, including the establishment of 

appropriate measure of the quality of care; 

● The evaluation of costs composite, including establishment of appropriate measures of 
CMS-1590-P 619 

costs; 

● The dates of implementation of the value-based payment modifier; 

● The specification of the initial performance period and any other performance period; 

● The application of the value-based payment modifier; and 

● The determination of costs. 

 Despite the prohibition of administrative and judicial review, we believe it is useful for 

groups of physicians to understand how their payment under the PFS could be changed by the 

value-based payment modifier. We also believe that a mechanism is needed for groups of 

physicians to review and to identify any possible errors prior to application of the value-based 

payment modifier. 

 Therefore, we intend to disseminate Physician Feedback reports containing calendar year 

2013 data in the fall of 2014 that encompass all physicians (individually or in groups of 

physicians, as applicable); these reports would be the basis of the value-based payment modifier 

in 2015. We propose that these reports would contain, among other things, the quality and cost 

measures and measure performance and benchmarks used to score the composites, and quality of 

care and cost composite scores, and the value-based payment modifier amount. 

 After the dissemination of the Physician Feedback reports in the fall of 2014, we propose 

that physicians would be able to e-mail or call a technical help desk to inquire about their report 

and the calculation of the value-based payment modifier. We envision this process to help 

educate and inform physicians about the value-based payment modifier, especially for those 

groups of physicians that have elected that their value-based payment modifier be calculated 

using a quality-tiering approach. We note that because we have proposed to align our proposals 

with the PQRS satisfactory reporting criteria, groups of physicians will be able to avail 

themselves of the informal review process regarding the PQRS payment adjustment as well. We 
CMS-1590-P 620 

do not envision providing opportunities for review of a value-based payment modifier. 

 In anticipation of the reports that we would produce in 2014, in the fall of 2013 we plan 

to produce and disseminate Physician Feedback reports at the TIN level to all groups of 

physicians with 25 or more eligible professionals based on 2012 data. These reports will 

include a “first look” at the methodologies we are proposing in this rule for the value-based 

payment modifier. We view these reports as a way to help educate groups of physicians about 

how the value-based payment modifier could affect their payment under the PFS. 

j. Physician Scenario and the Value-Based Payment Modifier Proposals 

The following example summarizes and pulls together our proposals for the payment 

modifier based on a group of physicians that satisfactorily reports quality measures through the 

PQRS GPRO web-interface and elects to have the value-based payment modifier calculated 

using the proposed quality-tiering methodology. 

● Quality measures: A large medical practice group with more than 100 physicians each 

billing under the same TIN could choose to submit data on a common set of quality measures via 

the PQRS web-interface. This group of physicians would need to meet the applicable and 

proposed self-nomination requirements under the PQRS to report data under this option. After 

approval to participate, CMS would provide the group of physicians in early 2014 a list of 

patients pre-loaded into the GPRO web-interface on which they would be required to report the 

measures to CMS. They would complete the web-interface during the first calendar quarter of 

2014. 

● Composite quality score: To arrive at the quality composite score, we would create a 

standardized score for each quality measure included in the GPRO web-interface and then 

combine these scores into the quality composite. Specifically, for each measure we would divide 

the difference between the group’s performance rate and the benchmark (the national mean 
CMS-1590-P 621 

computed across all groups of physicians and individual physicians submitting data on the quality 

measure) by the measure’s standard deviation to create a standardized unit. Standardized units 

representing each measure are then combined into quality domains with each measure weighted 

equally. We would then equally weight the domains to form the quality composite score. 

● Composite cost score: CMS will calculate five cost measures for the attributed 

beneficiaries. The standardized cost score composite is comprised of two cost domains: total per 

capita cost and condition-specific per capita costs. Each domain is weighted equally. For each 

cost measure, the difference between the group’s performance and the national mean is divided by 

the standard deviation computed across all groups of physicians. 

● Payment modifier: Using the quality composite, we would identify groups of 

physicians that have quality composite scores that are significantly different from the mean 

quality composite score of all groups of physicians. We would classify the groups of physicians 

into high, average, and low quality based on whether they are statistically above, not different 

from, or below the mean. 

We would also identify groups of physicians that have cost composite scores that are 

significantly different from the mean cost composite score and classify groups of physicians into 

high, average, and low cost. We would then compare the quality of care composite classification 

with the cost composite classification to determine the payment modifier according to the 

amounts in Table 70. 

Assuming the group of physicians had high quality and average cost, it would be eligible 

for an upward payment adjustment of +1x on each of its claims submitted for payment under the 

PFS during 2015. If the beneficiaries attributed to the group of physicians had an average risk 

score that was in the top 25 percent of all beneficiary risk scores, the upward payment adjustment 
CMS-1590-P 622 

would be increased to +2x. We would indicate the exact amount of the upward payment 

adjustment in the Physician Feedback report that we produced in the fall of 2014. 

(4) Physician Feedback Program 

 Section 1848(n) of the Act requires us to provide confidential reports to 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 September 2011, we produced and disseminated 

confidential feedback reports to physician groups that participated in the PQRS Group Practice 

Reporting Option (GPRO) in 2010, and in March 2012 we produced and disseminated reports to 

physicians practicing in the following States: Iowa, Kansas, Missouri, and Nebraska. 

(a.) CY 2010 Physician Group Feedback Reports based on 2010 data and disseminated in 2011 

In September 2011, we produced and distributed confidential Physician Feedback 

reports to each of the 35 medical group practices that participated in the 2010 GPRO of the 

PQRS. Each report provided information on the quality of care and resource use for Medicare 

FFS beneficiaries treated by the medical groups in 2010. More information about the 

methodologies used in these reports and the aggregate findings from these reports is available at 

http://www.cms.gov/physicianfeedbackprogram. 

 To participate in the 2010 PQRS GPRO, a group practice had to be a single provider 

entity, identified by its TIN, with at least 200 eligible professionals. Thirty-five groups, 

encompassing 24,823 eligible professionals, participated in the 2010 PQRS GPRO reporting 

option. On average, each group practice contained the following type of medical professionals: 

primary care (27 percent), medical specialties (20 percent), surgeons (13 percent), other medical 

professionals (36 percent) and ER physicians represented less than 1 percent. Despite the 

average group practice profile, five group practices were composed of substantially more 
CMS-1590-P 623 

medical specialists and surgeons than primary care professionals. A professional’s medical 

specialty was determined based on the CMS medical specialty code listed most often on their 

2010 Part B claims. 

 For each of the 35 participating group practices, we attributed Medicare FFS 

beneficiaries to the group practice if eligible professionals in the group practice billed for at 

least two office visits or other outpatient E&M services and the group practice had the plurality 

of E&M charges for that beneficiary. The average beneficiary population attributed to a group 

practice was 12,550 beneficiaries with the smallest group practice attributed 2,424 beneficiaries 

and the largest with 31,006 beneficiaries. 

 In 2010, each beneficiary that was attributed to a group practice had an average of 10 

total E&M visits in 2010 (both to physicians in and outside the group practice), ranging from a 

low of nine visits per group practice to a high of 14 visits per group practice. Seven of these 

E&M visits, on average, were with physicians in the group practice, ranging from a low of five 

E&M visits to a high of nine E&M visits with physicians in the group practice. Thus, the 

GPRO groups provided not only the plurality, but the large majority, of E&M visits to the 

beneficiaries attributed to that group practice. On average, the group practices accounted for 78 

percent of attributed beneficiaries’ E&M visits. 

 Primary care physicians, on average among all 35 groups, furnished over half (53 

percent) of the plurality of E&M visits within the group practice, followed by medical 

specialists at 27 percent. Surgeons provided 11 percent of the plurality of E&M visits and other 

physicians furnished 9 percent. We note that for five group practices medical specialists, rather 

than primary care providers, furnished the plurality of care for the attributed beneficiaries. 

Table 72 shows the mean performance rate and the performance rates for the 10th, 50th, 

and 90th percentiles for each of the 26 quality measures that were included in the PQRS GPRO 
CMS-1590-P 624 

measure set for 2010. We calculated the performance rates based on the data submitted by each 

of the group practices. Table 72 also shows the mean performance rate for those 19 measures 

that were included in the PQRS GPRO that eligible professionals also reported at an individual 

level through the PQRS. The mean group practice performance rate was equal to or higher than 

the individual performance rate for 16 of the 19 measures. 

TABLE 72: Performance Rates on 26 Quality Measures for Individual Eligible Physicians 

and Groups 

Performance Rate for All 

2010 GPROs 

Measure Percentile 

Number 

Measure 

Title 

2010 

Average 

Individual 

Performance 

Rate/Eligible 

Professional 

Mean 10th 50th 90th

 DIABETES 

GPRO 

DM-1 

Diabetes Mellitus: Hemoglobin A1C Testing NA 93% 88% 94% 98% 

GPRO 

DM-2* 

Diabetes Mellitus: Hemoglobin A1C Poor Control 

in Diabetes Mellitus 

22% 22% 11% 21% 39% 

GPRO 

DM-3 

Diabetes Mellitus: High Blood Pressure Control in 

Diabetes Mellitus 

59% 58% 49% 57% 67% 

GPRO 

DM-5 

Diabetes Mellitus: Low Density Lipoprotein ( 

LDL-C) Control in Diabetes Mellitus 

57% 54% 41% 55% 66% 

GPRO 

DM-6 

Diabetes Mellitus: Urine Screening for 

Microalbumin or Medical Attention for 

Nephropathy in Diabetic Patients 

74% 89% 82% 89% 96% 

GPRO 

DM-8 

Diabetes Mellitus: Foot Exam 72% 61% 16% 69% 86% 

GPRO 

DM-9 

Diabetes Mellitus: Lipid Profile NA 84% 75% 84% 93% 

HEART FAILURE 

GPRO HF1 Heart Failure: Left Ventricular ( LVF) Assessment 46% 86% 68% 93% 97% 

GPRO HF2 Heart Failure: Left Ventricular ( LVF) Testing NA 86% 68% 90% 98% 

GPRO HF3 Heart Failure: Weight Measurement NA 86% 79% 88% 96% 

GPRO HF5 Heart Failure: Patient Education 43% 77% 54% 83% 97% 

GPRO HF6 Heart Failure: Beta Blocker Therapy for Left 

Ventricular Systolic Dysfunction ( LVSD) 

83% 92% 86% 95% 99% 

GPRO HF7 Heart Failure: Angiotenson-Converting Enzyme 

(ACE) Inhibitor or Angiotensin Receptor Blocker ( 

ARB) Therapy for Left Ventricular Systolic 

Dysfunction ( LVSD) 

86% 90% 82% 91% 97% 

GPRO HF8 Heart Failure: Warfarin Therapy For Patients With 

Atrial 

Fibrillation 

72% 79% 62% 82% 94% 

CORONARY ARTERY DISEASE 
CMS-1590-P 625 

Performance Rate for All 

2010 GPROs 

Measure Percentile 

Number 

Measure 

Title 

2010 

Average 

Individual 

Performance 

Rate/Eligible 

Professional 

Mean 10th 50th 90th

GPRO 

CAD-1 

Coronary Artery Disease ( CAD): Oral Antiplatelet 

Therapy Prescribed for patients with CAD 

85% 85% 50% 93% 97% 

GPRO 

CAD-2 

Coronary Artery Disease ( CAD): Drug Therapy for 

Lowering LDL- Cholesterol 

75% 90% 85% 92% 97% 

GPRO 

CAD-3 

Coronary Artery Disease ( CAD): Beta Blocker 

Therapy for CAD Patients with Prior Myocardial 

Infarction 

71% 87% 76% 88% 95% 

GPRO 

CAD-7 

Coronary Artery Disease ( CAD): AngiotensinConverting Enzyme ( ACE) Inhibitor or 

Angiotensin Receptor Blocker ( ARB) Therapy for 

Patients with CAD and Diabetes and /or Left 

Ventricular Systolic Dysfunction 

( LVSD) 

67% 83% 75% 84% 91% 

HYPERTENSION 

GPRO 

HTN-1 

Hypertension ( HTN): Blood Pressure Measurement NA 92% 72% 98% 100% 

GPRO 

HTN-2 

Hypertension ( HTN): Blood Pressure Control NA 68% 58% 68% 76% 

GPRO 

HTN-3 

Hypertension ( HTN): Plan of Care NA 56% 21% 61% 79% 

PREVENTIVE CARE AND SCREENING 

GPRO 

PREV-5 

Preventive Care and Screening: Screening 

Mammography 

54% 74% 63% 76% 85% 

GPRO 

PREV-6 

Preventive Care and Screening: Colorectal Cancer 

Screening 

52% 60% 37% 64% 76% 

GPRO 

PREV-7 

Preventive Care and Screening: Influenza 

Immunization for Patients > 50 Years Old 

51% 67% 50% 67% 79% 

GPRO 

PREV-8 

Preventive Care and Screening: Pneumonia 

Vaccination for Patients 

55% 62% 40% 62% 86% 

• DM-2 is a measure of poorly controlled blood sugar: Higher scores (and percentile rankings) on this measure reflect 

worse performance. 

 The group practice performance rates were statistically reliable at a high level across the 

vast majority of the measures. We examine reliability because the clinical measures are derived 

from samples of the group practice’s attributed beneficiaries. In this context, reliability means 

the group practices’ performance rates would be similar or the same if a different sample 

population of the group practice were used for quality measurement. The average reliability 

score for the group practices’ quality measures related to coronary artery disease ranged from 

0.86 to 0.99, for diabetes from 0.87 to 0.99, for heart failure from 0.79 to 0.99, for hypertension 

from 0.89 to 1.00, and for the preventive measures from 0.94 to 0.98. All groups’ quality 

measures achieved at least a 0.50 score with most group practices well above that level. 
CMS-1590-P 626 

 The percentage of primary care physicians in a group practice did not correlate with 

higher performance on the clinical care measures, even though the 26 quality measures focused 

on effective primary care. As noted above, in five group practices, medical specialists rather 

than primary care providers furnished care to the majority of attributed beneficiaries. Two of 

these five group practices were among the top five group practices overall across all quality 

measures. 

 In addition to the 26 quality measures included in the GPRO, the reports also contained 

each group practice’s performance on measures of avoidable hospitalizations for six ambulatory 

care sensitive conditions (ACSCs). These are conditions for which outpatient care can 

potentially prevent a hospital admission. The measures were based on measures developed by 

the Agency for Healthcare Research and Quality (AHRQ) and more information can be found at 

http://www.qualityindicators.ahrq.gov/modules/pqi_overview.aspx. 

 The six ambulatory care sensitive conditions include: (1) bacterial pneumonia; (2) 

urinary tract infection (UTI); (3) dehydration; (4) heart failure (HF); (5) chronic obstructive 

pulmonary disease (COPD); and (6) diabetes – a composite measure based on short-term 

diabetes complications, uncontrolled diabetes, long-term diabetes complications, and lower 

extremity amputation for diabetes. Table 73 shows the mean, as well as minimum, and 

maximum performance rate (as expressed in events per 1,000 beneficiaries) for each of the six 

ACSC measures of potentially preventable hospitalizations. 

TABLE 73: Performance Rates for the ACSCs

 (ACSC) Mean Minimum Maximum 

Diabetes 25 7 39 

COPD 95 53 142 

CHF 122 66 200 

Bacterial Pneumonia 12 7 20 

UTI 8 4 13 

Dehydration 3 0 11 
CMS-1590-P 627 

 We also examined five measures of cost: total per capita costs for beneficiaries 

attributed to the group practice and total per capita for beneficiaries that had the following four 

chronic conditions: diabetes, heart failure, chronic obstructive pulmonary disease, and coronary 

artery disease. 

 In calculating these measures, we first standardized the Medicare payments to ensure 

fair comparisons. Geographic variations in Medicare payments to providers can reflect factors 

unrelated to the care provided to beneficiaries. All Medicare payments have been standardized 

such that a given service is priced at the same level across all providers within the same facility 

type or setting, regardless of geographic location or differences in Medicare payment rates 

among facilities. More information about how CMS standardized payments can be found in the 

September 2011 document describing the methodologies used in the 2010 QRURs, which can 

be accessed at 

http://www.cms.gov/PhysicianFeedbackProgram/Downloads/2010_GPRO_QRUR_Detailed_M

ethodology.pdf. 

 The standardized total per capita costs for the 35 group practices for attributed 

beneficiaries was on average, $13,135. Thus on average, Medicare paid providers $13,135 per 

beneficiary attributed to each group practice. The range of total per capita costs was $9,124 to 

$24,480 and an absolute difference of $15,536 per beneficiary. 

 We applied a risk adjustment methodology to adjust these total per capita costs for 

patient demographics, socioeconomic factors, and prior health conditions, recognizing that 

physiologic differences among beneficiaries can affect their medical costs, regardless of the care 

provided. This risk adjustment methodology is based on the CMS’ Hierarchical Condition 

Categories (HCC) model that assigns ICD-9 diagnosis codes (each with similar disease 

characteristics and costs) to 70 clinical conditions to capture medical condition risk. The HCC 
CMS-1590-P 628 

risk scores also incorporate patient age, general reason for Medicare eligibility (aged or 

disabled), and Medicaid eligibility. The risk adjustment model also included the beneficiary’s 

end stage renal disease (ESRD) status. More information about how CMS risk adjusted per 

capita costs can be found in the September 2011 document describing the methodologies used 

in the 2010 QRURs, which can be accessed at 

http://www.cms.gov/PhysicianFeedbackProgram/Downloads/2010_GPRO_QRUR_Detailed_M

ethodology.pdf 

 After risk adjustment, the adjusted average total per capita costs was $12,652 with a 

range of $9,932 to $16,736 and an absolute difference of $6,804. Thus the risk adjustment 

methodology had the effect of reducing the absolute difference between the groups with the 

lowest and highest total per capita range 55.7 percent. In particular, the lowest third of the 

groups were adjusted upward by an average of 6.2 percent and the most expensive third were 

lowered by 10.4 percent. The middle third, on average, were adjusted downward by 0.1 

percent, but the range of adjustments was -10.3 to +8.2 percent. 

 Moreover, three of the five group practices for which medical specialists provided the 

plurality of care to attributed beneficiaries had their costs risk adjusted downward. Two of 

these five groups had their unadjusted per capita costs adjusted upward. 

 The physician feedback reports also showed the percentage of professionals who did not 

bill under the group practice’s TIN who treated the beneficiaries attributed to the group practice. 

On average, 42 percent of the professionals that cared for attributed patients were outside the 

group practice. The range was from 18 to 84 percent. We also found a weak association 

between the percent of professionals who did not bill under the group practice’s TIN and total 

per capita costs for the attributed beneficiaries. The correlation was 0.12. 

 All 35 group practices achieved statistical reliability scores greater than 0.70 for the 
CMS-1590-P 629 

overall per capita cost measures and the four subgroup-specific cost measures. In particular, the 

group practices achieved an average reliability score of 0.99 for the overall per capita cost 

measure. In addition, all 35 group practices achieved a reliability of greater than 0.70 across all 

sub cost categories. The average reliabilities were 0.93 for heart failure, 0.91 for COPD, 0.95 

for diabetes, and 0.96 for CAD. 

 Although the sample of group practices was small (35), we found almost no association 

between quality of care furnished and the total risk-adjusted per capita cost for each group 

practice. We constructed a simple quality score by taking the average of the 32 performance 

rates (26 clinical quality measures and six ACSC rates). We translated the ACSC rates into 

percentages with the lowest ACSC rate equal to 100.0 percent (because lower rates are better) 

and the highest ACSC rate equal to 0.0 percent. Table 74 shows a scatter diagram of the 

relationship between the quality of care furnished by each group practice and the total riskadjusted per capita cost. The correlation between the two variables is 2.0 percent. 

TABLE 74: Quality of Care Compared To Cost 

(b.) Individual Physician Feedback reports based on 2010 data and disseminated in 2012. 
CMS-1590-P 630 

 In March 2012, we produced and made available for download confidential individual 

Physician Feedback reports for 23,730 physicians enrolled in Medicare and practicing in Iowa, 

Kansas, Missouri, and Nebraska. Each report provided information on the quality of care and 

resource use for Medicare FFS beneficiaries treated by the physician in 2010. Each report 

contained two sets of quality measures for Medicare beneficiaries: measures physicians 

reported in the PQRS via the claims-based reporting methodology, and quality measures 

calculated by CMS that relied solely on Medicare administrative claims data. 

 Approximately 25 percent (5,891) of the 23,730 physicians reported on one or more 

PQRS measure in 2010. The five specialties with the highest participation rates, as a percentage 

of the total number of physicians in that specialty, were Ophthalmology, Anesthesiology, 

Gynecology/Oncology, Pathology, and Geriatric Medicine. Physicians reported 3.7 PQRS 

measures on average. The maximum number of measures reported was 30, by a family 

practitioner. 

 The PQRS performance rates were strongly skewed upward and compressed for the 

physicians in the four states. For approximately three quarters of the measures, the 50th

percentile was 100 percent. For approximately one-third of the measures, the 25th percentile 

was 100 percent. The most frequently reported PQRS measure was “Health Information 

Technology: Adoption/Use of Electronic Health Records”, reported by 1,494 physicians (6.3 

percent). The 2010 Reporting Experience report has more information on PQRS performance 

rates nationwide and it is available at http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/PQRS/index.html?redirect=/PQRI. 

The reports also contained information on up to 28 administrative claims-based quality 

measures (and 13 sub-measures for a total of 41 measures) depending upon whether the 

physician treated at least one beneficiary that was eligible for the measure, that assessed 
CMS-1590-P 631 

whether Medicare FFS beneficiaries received recommended primary care and preventive care 

services. We calculated these measure performance rates solely from Medicare FFS claims 

data. The measurement year used for calculating performance was January 1 - December 31, 

2010; claims were available for a one-year look-back period to January 1, 2009, for measures 

requiring a look-back period. Specifications for these measures are available at 

http://www.cms.gov/PhysicianFeedbackProgram/Downloads/claims_based_measures_with_des

criptions_num_denom_excl.pdf. 

On average, a physician’s report contained information on 30 of 41 measures. The 

reports provided this information for any beneficiary to whom the physician furnished at least 

one service, even if the physician did not provide the treatment indicated by the quality 

measure. We provided this information because we believe it is critical to inform physicians 

about the quality of care that their beneficiaries received for primary care and preventive 

services from any Medicare FFS physician. Moreover, physicians may be unaware of the care 

that that their beneficiaries receive. Table 75 shows the percentage of Medicare FFS patients 

who received the treatment indicated by the quality measure. There is room for improvement 

for physicians to provide basic recommended services in many clinical areas, especially those 

where the percentage of beneficiaries receiving the indicated treatment is less than 50 percent. 

TABLE 75: Physician Performance on Medicare Claims–Based Quality Measures 

for 2010 QRUR Physicians (Iowa, Kansas, Missouri, Nebraska) 

Mean Performance Rate

Clinical Condition and Measure Physicians in Iowa, Kansas, 

Missouri, and Nebraska

Specifications for these clinical measures are posted at 

http://www.cms.gov/PhysicianFeedbackProgram/Downloads

/claims_based_measures_with_descriptions_num_denom_excl.pdf. Number of 

Physicians 

Included

Percentage of

Medicare 

Patients Who 

Received 

the Service

Chronic Obstructive Pulmonary Disease (COPD)

Pharmacotherapy Management of COPD Exacerbation 

1. Dispensed Systemic Corticosteroid Within 14 Days of Event 18,472 66% 

2. Dispensed Bronchodilator Within 30 Days of Event 18,472 66% 
CMS-1590-P 632 

Mean Performance Rate

Clinical Condition and Measure Physicians in Iowa, Kansas, 

Missouri, and Nebraska

Specifications for these clinical measures are posted at 

http://www.cms.gov/PhysicianFeedbackProgram/Downloads

/claims_based_measures_with_descriptions_num_denom_excl.pdf. Number of 

Physicians 

Included

Percentage of

Medicare 

Patients Who 

Received 

the Service

Use of Spirometry Testing to Diagnose COPD 22,290 33% 

 Bone, Joint, and Muscle Disorders

Osteoporosis Screening for Chronic Steroid Use 17,046 58% 

Osteoporosis Management in Women ≥ 67 Who Had a Fracture 19,678 14% 

Disease-Modifying Antirheumatic Drug Therapy for Rheumatoid Arthritis 18,094 77% 

Cancer

Breast Cancer Surveillance for Women with a History of Breast Cancer 15,550 78% 

PSA Monitoring for Men with Prostate Cancer 17,598 89% 

Diabetes

Dilated Eye Exam for Beneficiaries ≤ 75 with Diabetes 23,012 71% 

HbA1c Testing for Beneficiaries ≤ 75 with Diabetes 23,012 87% 

Urine Protein Screening for Beneficiaries ≤ 75 with Diabetes 23,012 74% 

Lipid Profile for Beneficiaries ≤ 75 with Diabetes 23,012 77% 

Gynecology

Endometrial Sampling or Hysteroscopy with Biopsy Before Endometrial

Ablation Procedure 3,704 53% 

Heart Conditions

Statin Therapy for Beneficiaries with Coronary Artery Disease 

1. Percentage Prescribed Statin Therapy 20,909 71% 

2. Average Medication Possession Ratio* 20,172 80% 

3. Percentage with Medication Possession Ratio ≥ 0.80* 20,172 64% 

Persistence of Beta Blocker Treatment After Heart Attack 10,381 57% 

Lipid Profile for Beneficiaries with Ischemic Vascular Disease 22,130 44% 

Human Immunodeficiency Virus (HIV)

Monitoring for Disease Activity for Beneficiaries with HIV 13,345 39% 

Mental Health

Antidepressant Treatment for Depression 

1. Acute Phase Treatment (at least 12 weeks) 16,224 54% 

2. Continuation Phase Treatment (at least 6 months) 16,224 39% 

Follow-Up After Hospitalization for Mental Illness 

1. Percentage of Patients Receiving Follow-Up Within 30 Days 18,562 63% 

2. Percentage of Patients Receiving Follow-Up Within 7 Days 18,562 33% 

Prevention

Breast Cancer Screening for Women ≤ 69 23,021 64% 

Medication Management

Viral Load Testing for Beneficiaries with Antiviral Therapy for Hepatitis C 1,212 93% 

Lipid Profile for Beneficiaries Who Started Lipid-Lowering Medications 22,632 41% 

Annual Monitoring for Beneficiaries on Persistent Medications 

1. Angiotensin Converting Enzyme (ACE) Inhibitors or Angiotensin Receptor 

Blockers (ARB) 22,010 93% 

2. Digoxin 15,167 93% 
CMS-1590-P 633 

Mean Performance Rate

Clinical Condition and Measure Physicians in Iowa, Kansas, 

Missouri, and Nebraska

Specifications for these clinical measures are posted at 

http://www.cms.gov/PhysicianFeedbackProgram/Downloads

/claims_based_measures_with_descriptions_num_denom_excl.pdf. Number of 

Physicians 

Included

Percentage of

Medicare 

Patients Who 

Received 

the Service

3. Diuretics 21,905 93% 

4. Anticonvulsants 1,712 39% 

5. Total Rate (sum of 4 previous numerators divided by sum of 4 previous 

denominators) 22,385 92% 

Anticoagulation Treatment ≥ 3 Months After Deep Vein Thrombosis 14,787 43% 

Anticoagulation Treatment ≥ 3 Months After Pulmonary Embolism 10,298 44% 

International Normalized Ratio (INR) Testing for Beneficiaries Taking

Warfarin and Interacting Anti-Infective Medications 14,006 14% 

NOTE: For the measures shown below, lower percentages reflect better performance

Drugs to Be Avoided for Beneficiaries ≥ 65

1. Patients Who Receive at Least One Drug to Be Avoided 23,085 27% 

2. Patients Who Receive at Least Two Different Drugs to Be Avoided 23,085 16% 

Potentially Harmful Drug-Disease Interactions for Beneficiaries ≥ 65

1. Prescription for Tricyclic Antidepressants, Antipsychotics, or Sleep Agents 

for Patients with a History of Falls 21,132 18% 

2. Prescription for Tricyclic Antidepressants or Anticholinergic Agents for 

Patients with Dementia 21,443 29% 

3. Prescription for Nonaspirin NSAIDs or Cox-2 Selective NSAIDs for 

Patients with Chronic Renal Failure 16,902 8% 

4. Total Rate (sum of 3 previous numerators divided by sum of 3 previous 

denominators) 22,232 22% 

Lack of Monthly INR Monitoring for Beneficiaries on Warfarin 21,967 48% 

*Unlike the other measures in this table, these values represent a ratio, not a percentage of patients receiving the service. 

The reports also provided information on five measures of per capita cost. Total per 

capita costs for beneficiaries attributed to the physician and total per capita costs for 

beneficiaries that had the following four chronic conditions: diabetes; heart failure; chronic 

obstructive pulmonary disease (COPD); and coronary artery disease (CAD). As discussed 

earlier, we standardized and risk adjusted the total per capita cost measures. 

To assess per capita cost measures, we attributed beneficiaries to physicians. To 

attribute beneficiaries, the reports classified each physician’s Medicare FFS beneficiaries into 

three groups based upon the degree of the physician’s involvement with the patient: 

● Directed: The physician billed for 35 percent or more of the patient’s office or other 

outpatient Evaluation and Management (E&M) visits. 
CMS-1590-P 634 

● Influenced: The physician billed for fewer than 35 percent of the patient’s outpatient 

E&M visits, but for 20 percent or more of the patient’s total professional costs. 

● Contributed: The physician billed for fewer than 35 percent of the patient’s 

outpatient E&M visits, and for less than 20 percent of the patient’s total professional costs. 

 As discussed with reference to the value-based payment modifier, this attribution 

methodology assigns the same patient to all physicians who treated the patient, but classifies the 

patient based on how involved the physician was with the care provided to the patient. 

 Table 76 shows the number of beneficiaries attributed, on average, to physicians under 

each of these rules. We wish to highlight two observations. First, that primary care physicians 

generally furnished services to fewer patients than surgeons/specialists and other types of 

physicians (which included radiologists, anesthesiologists, and pathologists) and that primary 

care physicians directed care more often than other types of physicians. Second, there were 

several physicians in all categories who only contributed to care, meaning that care can 

frequently be fragmented. This finding highlights the importance of coordinating care among 

physicians. 

TABLE 76: Beneficiaries in Iowa, Kansas, Missouri, and Nebraska Attributed by 

Physician Type: Average Number of Beneficiaries 

Type of 

Physician 

Average 

Number of 

Attributed 

Beneficiaries 

Average 

Number of 

Directed 

Beneficiaries 

Average 

Number of 

Influenced 

Beneficiaries 

Average 

Number of 

Contributed 

Beneficiaries 

Primary care 279 105 13 181 

Medical 

specialist 

471 59 51 381 

Surgeons 309 36 64 217 

Emergency 

medicine 

367 35 14 350 

Other 860 18 34 840 

We calculated total per capita costs for each type of attribution of patients. As discussed 
CMS-1590-P 635 

above and shown in Table 77, the beneficiaries who receive care under the “contributed only” 

attribution have substantially higher per capita costs and accounted for 20 percent of those 

beneficiaries covered by the 2010 individual reports. 

TABLE 77: Mean Total Per Capita Costs in the QRURs 

Type of 

Physician 

Overall Directed Influenced Contributed 

Primary care $16,580 $9,733 $6,780 $19,019 

Medical 

specialist 

19,765 11,256 9,219 21,276 

Surgeons 17,535 11,482 15,182 18,313 

Emergency 

medicine 

20,729 10,389 3,675 21,217 

Other 23,704 11,442 8,987 23,980 

(c.) Physician Feedback Program Dissemination Strategy 

Based on our previous dissemination of individual Physician Feedback reports, we have 

learned that the overwhelming factor that prevents physicians from accessing their reports is 

lack of knowledge of their availability. We undertook several steps this year to increase 

awareness of the Physician Feedback reports. First, we increased the information we provided 

to physicians about the feedback reports, performance reporting, the value-based payment 

modifier, and our methodology via www.cms.gov/physicianfeedbackprogram, fact sheets, 

FAQs, video, slides, national provider calls, targeted conference calls with report recipients, 

meetings with national and local medical associations and specialties, and multiple physician 

fee for service list serve announcements. We also partnered with the J5 Medicare 

Administrative Contractor (MAC), WPS, for Iowa, Kansas, Nebraska, and Missouri, to develop 

a secure internet portal where physician could easily obtain their reports. As of June 10, 2012, 

7,484 of approximately 24,000 (31 percent) individual Physician Feedback reports have been 

accessed electronically. This is a substantial increase from earlier phases of the Physician 

Feedback program in which only 1 percent of physicians obtained their reports. 
CMS-1590-P 636 

We also have aggressively solicited feedback from physicians and physician groups, 

including the American Medical Association, on how to increase the usefulness of the reports so 

that physicians and groups of physicians would actively seek this type of information from 

CMS. We invited report recipients (via several conference calls directed first to medical 

practice groups and then individual physicians) to provide us input on the usefulness and 

credibility of the performance measures, and other information contained in the reports so that 

we can improve the reports for future years. 

Following the September 26, 2011 distribution of reports to physician groups, we hosted 

two conference calls for the 35 large medical practice groups. In addition to “walking through” 

a sample template of the group performance report, we responded to questions and followed up 

with an aggregation of questions/issues raised by groups and corresponding answers and 

explanations from CMS. These reports represent the first time performance on a wide-range of 

quality and cost measures can be viewed in the same report for Medicare beneficiaries in large 

group practices across the country. 

After the March 2012 dissemination of individual reports, we conducted National 

Provider Calls on April 3, 2012 and April 5, 2012 at which time we reported some initial 

observations, reviewed a report template page by page, and answered questions from the call 

participants. On May 8, 2012 and June 4, 2012, we held another call in conjunction with the 

MAC, WPS, to obtain targeted feedback on the feedback reports and how they could be 

improved and made more useful. We view the physician feedback reports as a way to test 

various methods of analyzing and displaying comparative performance information and 

previewing methods that will be further developed for use in the value-based payment modifier. 

In addition, we have responded to over 50 requests for more information from the Help Desk 

we established for the program. 
CMS-1590-P 637 

(d.) Future Plans for the Physician Feedback Reports 

 In the fall of 2012, we plan to disseminate Physician Feedback reports to all physicians 

in nine states (California, Iowa, Illinois, Kansas, Michigan, Minnesota, Missouri, Nebraska, and 

Wisconsin) based on 2011 data. These reports will contain the PQRS measures that physicians 

in these states submitted via enhanced claims, as well as information on 28 administrative 

claims measures included in the 2010 reports. We also will produce and disseminate Physician 

Feedback reports to the groups of physicians that reported measures through the PQRS GPRO 

web interface in 2011. We have adjusted and improved the content and organization of the 

Physician Feedback reports that we plan to produce later this year based on the comments we 

received from the Program Year 2010 report recipients. We plan to increase our outreach 

efforts to encourage physicians to view their reports, to begin to understand the methodologies 

we have proposed for the value-based payment modifier and that are included in the 2011 

reports, and to provide suggestions on how we can make these reports more meaningful and 

actionable in the future. 

 In the fall of 2013, we plan to produce and disseminate Physician Feedback reports at 

the TIN level to all groups of physicians with 25 or more eligible professionals and to individual 

physicians that satisfactorily reported measures through PQRS in 2012 using any of the PQRS 

reporting mechanisms. These reports will include a “first look” at the methodologies that we 

are proposing in this rule for the value-based payment modifier. 

In addition, section 1848(n) of the Act requires that we use the episode-based costs in 

the Physician Feedback reports beginning in 2013 for the reports based on 2012 data. As 

discussed above in relation to the value-based payment modifier, we plan to include episodebased cost measures for several episode types in these Physician Feedback reports. In addition, 

we plan to consider adjusting the format and organization of the reports, to the extent 
CMS-1590-P 638 

practicable, to address the best practices outlined in the AMA’s Guidelines for Reporting 

Physician Data. We believe that this dissemination plan satisfies our obligations under the 

section 1848(p)(4)(B)(ii)(II) of the Act to provide information to physicians and groups of 

physicians about the quality of care furnished to Medicare FFS beneficiaries. 

 In the fall of 2014, we plan to disseminate Physician Feedback reports based on 2013 

data that show the amount of the value-based payment modifier and the basis for its 

determination. We plan to provide these reports to all groups of physicians (at the TIN level) 

with 25 or more eligible professionals. We are examining whether we can provide reports to 

groups of physicians with fewer than 25 eligible professionals and to individual level reports as 

well. These reports will contain, among other things, performance on the quality and cost 

measures used to score the composites and the value-based payment modifier amount. As 

discussed above, we anticipate providing an opportunity for review and correction as outlined in 

our value-based payment modifier proposals above. 

L. Medicare Coverage of Hepatitis B Vaccine

1. Modification of high risk groups eligible for Medicare Part B coverage of Hepatitis B 

vaccine. 

a. Background and Statutory Authority – Medicare Part B Coverage of Hepatitis B Vaccine 

Section 1861(s)(10)(B) of the Act authorizes Medicare Part B coverage of hepatitis B 

vaccine and its administration if furnished to an individual who is at high or intermediate risk of 

contracting hepatitis B. High and intermediate risk groups are defined in regulations at §410.63. 

 On December 23, 2011, the United States Centers for Disease Control and Prevention 

(CDC) published a Morbidity and Mortality Weekly Report, which included an article entitled 

“Use of Hepatitis B Vaccination for Adults with Diabetes Mellitus: Recommendations of the 

Advisory Committee on Immunization Practices (ACIP).” The article stated that “In the United 
CMS-1590-P 639 

States, since 1996, a total of 29 outbreaks of HBV [Hepatitis B virus] infection in one or multiple 

long-term care (LTC) facilities, including nursing homes and assisted-living facilities, were 

reported to CDC; of these, 25 involved adults with diabetes receiving assisted blood glucose 

monitoring. These outbreaks prompted the Hepatitis Vaccines Work Group of the Advisory 

Committee on Immunization Practices (ACIP) to evaluate the risk for HBV infection among all 

adults with diagnosed diabetes.” 

“HBV is highly infectious and environmentally stable; HBV can be transmitted by 

medical equipment that is contaminated with blood that is not visible to the unaided eye. 

Percutaneous exposures to HBV occur as a result of assisted monitoring of blood glucose and 

other procedures involving instruments or parenteral treatments shared between persons. Lapses 

in infection control during assisted blood glucose monitoring that have led to HBV transmission 

include multipatient use of finger stick devices designed for single-patient use and inadequate 

disinfection and cleaning of blood glucose monitors between patients. Breaches have been 

documented in various settings, including LTC facilities, hospitals, community health centers, 

ambulatory surgical centers, private offices, homes, and health fairs.” Additionally, in analyses 

of persons without hepatitis B-related risk behaviors (that is, injection-drug use, male sex with a 

male, and sex with multiple partners), persons aged 23 through 59 years with diabetes had 2.1 

times the odds of developing acute hepatitis B as those without diabetes; and the odds for 

hepatitis B infection were 1.5 times as likely for persons aged 60 and older. (MMWR, 

December 23, 2011). 

Based on the Hepatitis Vaccines Work Group findings, ACIP recommended that: 

● Hepatitis B vaccination should be administered to unvaccinated adults with diabetes 

mellitus who are aged 19 through 59 years. 

● Hepatitis B vaccination may be administered at the discretion of the treating clinician 
CMS-1590-P 640 

to unvaccinated adults with diabetes mellitus who are aged 60 years and older. 

b. Implementation 

Based on the ACIP recommendations, we propose to modify §410.63(a)(1), High Risk 

Groups, by adding new paragraph “(viii) persons diagnosed with diabetes mellitus.” Since HBV 

can be transmitted by medical equipment (that is, finger stick devices and blood glucose 

monitors) that is contaminated with blood that is not visible to the unaided eye, we believe that 

persons diagnosed with diabetes mellitus should be added the high risk group. Since lapses in 

infection control have been reported in both community and facility settings, the increased risk 

of contracting HBV is not limited to the facility setting. We believe that expanding coverage of 

Hepatitis B vaccinations and administration to those diagnosed with diabetes mellitus is 

supported by the findings and evidence reviewed by the Hepatitis Vaccines Work Group and the 

ACIP recommendations. Hepatitis B vaccination is a preventive measure that needs to occur 

before exposure. It is difficult to predict which diabetics will eventually be exposed in the 

circumstances that we discussed above. Therefore, we are proposing to expand coverage for 

hepatitis B vaccine and its administration to all individuals diagnosed with diabetes mellitus, not 

just those individuals with diabetes that are receiving glucose monitoring in facilities, for 

example, in nursing homes. 

M. Updating Existing Standards for E-prescribing under Medicare Part D and Lifting the LTC 

exemption.

1. Background 

a. Legislative History 

Section 101 of the Medicare Prescription Drug, Improvement, and Modernization Act of 

2003 (MMA) (Pub. L. 108-173) amended title XVIII of the Social Security Act (the Act) to 

establish a voluntary prescription drug benefit program at section 1860D-4(e) of the Social 
CMS-1590-P 641 

Security Act. Among other things, these provisions required the adoption of Part D e-prescribing 

standards. Prescription Drug Plan (PDP) sponsors and Medicare Advantage (MA) organizations 

offering Medicare Advantage-Prescription Drug Plans (MA-PD) are required to establish 

electronic prescription drug programs that comply with the e-prescribing standards that are 

adopted under this authority. There is no requirement that prescribers or dispensers implement 

e-prescribing. However, prescribers and dispensers who electronically transmit prescription and 

certain other information for covered drugs prescribed for Medicare Part D eligible beneficiaries, 

directly or through an intermediary, are required to comply with any applicable standards that are 

in effect. 

For a further discussion of the statutory basis for this proposed rule and the statutory 

requirements at section 1860D-4(e) of the Act, please refer to section I. (Background) of the EPrescribing and the Prescription Drug Program proposed rule, published February 4, 2005 (70 

FR 6256). 

b. Regulatory History 

(1) Foundation and Final Standards 

(a) Adopting and updating: 

CMS utilized several rounds of rulemaking to adopt standards for the e-prescribing 

program. Its first rule, which was published on November 7, 2005 (70 FR 67568), adopted three 

standards that were collectively referred to as the “foundation” standards. One of these 

standards, the National Council for Prescription Drug Programs (NCPDP) SCRIPT Standard, 

Implementation Guide, Version 5, Release 0 (Version 5.0), May 12, 2004 (excluding the 

Prescription Fill Status Notification Transaction and its three business cases; Prescription Fill 

Status Notification Transaction--Filled, Prescription Fill Status Notification Transaction--Not 

Filled, and Prescription Fill Status Notification Transaction--Partial Fill), hereafter referred to as 
CMS-1590-P 642 

the NCPDP SCRIPT 5.0, is the subject of several of the proposals in this rule. CMS issued a 

subsequent rule on April 7, 2008 (73 FR 18918) that adopted additional standards which are 

referred to as “final” standards. One of these standards, version 1.0 of the NCPDP Formulary 

and Benefit standard, Implementation Guide, Version 1, Release 0, hereafter referred to as the 

NCPDP Formulary and Benefit 1.0) is also one of the subjects of this proposed rule. Please see 

the “Initial Standards Versus Final Standards” discussion at 70 FR 67568 in the November 7, 

2005 rule for a more detailed discussion about “foundation” and “final” standards. 

(b) Exemption from the NCPDP SCRIPT standard in long term care settings (LTC) 

 While prescribers and dispensers who electronically transmit prescription and certain 

other information for covered drugs prescribed for Medicare Part D eligible beneficiaries, 

directly or through an intermediary, are generally required to comply with any applicable 

standards that are in effect at the time of their transmission, the early versions of the NCPDP 

SCRIPT standard did not support the complexities of the prescribing process for patients in long 

term care facilities where the prescribing process involves not only a prescriber and a pharmacy, 

but also a facility and its staff. As such, we exempted such entities from use of the NCPDP 

SCRIPT standard. That exemption, currently found at §423.160(a)(3)(iv), provides an 

exemption for entities transmitting prescriptions or prescription-related information where the 

prescriber is required by law to issue a prescription for a patient to a non-prescribing provider 

(such as a nursing facility) that in turn forwards the prescription to a dispenser. 

For a more detailed discussion, see the November 7, 2005 final rule (70 FR 67583). 

 (2) Updating e-Prescribing Standards 

 Transaction standards are periodically updated to take new knowledge, technology and 

other considerations into account. As CMS adopted specific versions of the standards when it 

adopted the foundation and final e-prescribing standards, there was a need to establish a process 
CMS-1590-P 643 

by which the standards could be updated or replaced over time to ensure that the standards did 

not hold back progress in the industry. CMS discussed these processes in its November 7, 2005 

final rule (70 FR 67579). 

The discussion noted that the rulemaking process will generally be used to retire, replace 

or adopt a new e-prescribing standard, but it also provided for a simplified “updating process” 

when a standard could be updated with a newer “backward-compatible” version of the adopted 

standard. In instances in which the user of the later version can accommodate users of the earlier 

version of the adopted standard without modification, however, it noted that notice and comment 

rulemaking could be waived, in which case the use of either the new or old version of the 

adopted standard would be considered compliant upon the effective date of the newer version’s 

incorporation by reference in the Federal Register. CMS utilized this streamlined process when 

it published an interim final rule with comment on June 23, 2006 (71 FR 36020). That rule 

recognized NCPDP SCRIPT 8.1 as a backward compatible update to the NCPDP SCRIPT 5.0, 

thereby allowing for use of either of the two versions in the Part D program. Then, on April 7, 

2008, CMS used notice and comment rulemaking (73 FR 18918) to finalize the identification of 

the NCPDP SCRIPT 8.1 as a backward compatible update of the NCPDP SCRIPT 5.0, and, 

effective April 1, 2009, retire NCPDP SCRIPT 5.0 and adopt NCPDP SCRIPT 8.1 as the official 

Part D e-prescribing standard. Finally, on July 1, 2010, CMS utilized the streamlined process to 

recognize NCPDP SCRIPT 10.6 as a backward compatible update of NCPDP SCRIPT 8.1 in an 

interim final rule (75 FR 38026). 

In contrast to the extensive updating that was done to the NCPDP SCRIPT standard in 

the Part D e-prescribing program, the original NCPDP Formulary and Benefit 1.0 is still in place 

as the official Part D e-prescribing standard. 

2. Proposals for Calendar Year 2013 
CMS-1590-P 644 

 a. Proposed Finalization of NCPDP SCRIPT 10.6 as a Backward Compatible Version 

of NCPDP SCRIPT 8.1, Retirement of NCPDP SCRIPT 8.1 and Adoption of NCPDP SCRIPT 

10.6 as the official Part D E-Prescribing Standard 

 As described in greater detail below, we propose to finalize our recognition of NCPDP 

SCRIPT 10.6 as a backward compatible version of the official Part D e-prescribing standard 

NCPDP SCRIPT 8.1, effective from the effective date of the final rule through October 31, 2013, 

but, in response to the comments that were received to the interim final rule with comment, we 

also propose to retire NCPDP SCRIPT 8.1 effective October 31, 2013, and we propose to adopt 

NCPDP SCRIPT 10.6 as the official Part D e-prescribing standard effective November 1, 2013. 

 On July 1, 2010, we published an interim final rule with comment (75 FR 38026) 

which named NCPDP SCRIPT 10.6 as a backward compatible update to NCPDP SCRIPT 8.1. 

We received 7 timely public comments on this interim final rule with comment. The comments 

came from a standards setting organization, two national industry associations, two healthcare 

organizations and, two health information intermediaries. All commenters supported the 

voluntary use of NCPDP SCRIPT version 10.6 as a backward compatible version of the adopted 

NCPDP SCRIPT 8.1 standard. Five of the commenters recommended that Version 10.6 be 

adopted as the official standard for the Medicare Part D E-Prescribing Program with a time 

frame of full implementation of January 1, 2013. One commenter recommended that CMS adopt 

version 10.6 as the official Part D e-prescribing standard, and retire version 8.1, but did not 

suggest a date by which that should happen. Another commenter recommended that CMS adopt 

version 10.6 as early as January 1, 2012. All commenters agreed that version 8.1 should be 

retired when version 10.6 was adopted. 

 As we discussed in the July 1, 2010 interim final rule with comment (75 FR 38026) 

NCPDP SCRIPT 10.6 has a number of new functionalities that, if users elect to use them will 
CMS-1590-P 645 

mesh with their use of the adopted NCPDP SCRIPT 8.1, which was adopted in the April 7, 2008 

e-prescribing final rule (73 FR 18918). These new functions would allow users drug NDC source 

information, pharmacy prescription fill numbers and date of sale information that could then be 

used in a medication history response. These added functionalities would therefore be expected 

to facilitate better record matching, the identification and elimination of duplicate records, and 

the provision of richer information to the prescriber between willing trading partners. We 

therefore agree with commenters that NCPDP SCRIPT 10.6 would be appropriate as an official 

standard for the Medicare Part D e-Prescribing Program. At the time of this rule’s drafting, 

however, the suggested dates for the adoption of SCRIPT Version 10.6 as the official Part D eprescribing standard and the retirement of NCPDP SCRIPT 8.1 have either passed or are too near 

in the future to be a reasonable implementation date. Furthermore, since the time of these 

comments, industry stakeholders have worked with NCPDP, a standards development 

organization, and reached out to CMS with additional suggestions for appropriate 

implementation dates in light of the current state of the standards development process. 

Stakeholders working though NCPDP currently recommend retiring NCPDP SCRIPT 8.1 on 

October 31, 2013 and adoption of NCPDP Script 10.6 as the official Part D e-prescribing 

standard on November 1, 2013. We believe that this is a realistic timetable to retire NCPDP 

SCRIPT 8.1 and the adopt NCPDP SCRIPT 10.6 as the official Part D e-prescribing standard on 

the dates described. 

 As such, we propose to revise §423.160(b)(2)(ii) so as to limit its application to 

transactions on or before October 31, 2013 and add a new §423.160(b)(2)(iii) to require that, as 

of November 1, 2013, providers and dispensers use NCPDP SCRIPT 10.6 for the following 

electronic transactions that convey prescription or prescription related information: 

• Get message transaction. 
CMS-1590-P 646 

• Status response transaction. 

• Error response transaction. 

• New prescription transaction. 

• Prescription change request transaction. 

• Prescription change response transaction. 

• Refill prescription request transaction. 

• Refill prescription response transaction. 

• Verification transaction. 

• Password change transaction. 

• Cancel prescription request transaction. 

• Cancel prescription response transaction 

• Fill status notification. 

 Furthermore, we propose to amend §423.160(b)(1) by adding a new 423.160(b)(1)(iii) to 

amend the information about which subsequent requirements in the section are applicable to 

which timeframes and amend §423.160(b)(1)(ii) to limit its application to transactions on or 

before October 31, 2013. 

 As considerable time has passed since we solicited comments on the retirement of 

NCPDP SCRIPT 8.1, we are soliciting additional comments regarding the retirement of version 

8.1 on October 31, 2013. We also are soliciting comments on the adoption of Version 10.6 as 

the official Part D e-prescribing standard for the e-prescribing functions that will be outlined in 

§423.160(b)(1)(iii) and (b)(2)(iii), effective November 1, 2013. 

b. Proposed Recognition of NCPDP Formulary and Benefit Standard 3.0 as a Backward 

Compatible Version of the NCPDP Formulary and Benefit Standard 1.0, Proposed Retirement of 
CMS-1590-P 647 

NCPDP Formulary and Benefit Standard 1.0 and Proposed Adoption of NCPDP Formulary and 

Benefit Standard 3.0 

Formulary and Benefits standards provide a uniform means for pharmacy benefit payers 

(including health plans and PBMs) to communicate a range of formulary and benefit information 

to prescribers via point-of-care (POC) systems. These include: 

• General formulary data (for example, therapeutic classes and subclasses); 

• Formulary status of individual drugs (that is, which drugs are covered); 

• Preferred alternatives (including any coverage restrictions, such as quantity limits and 

need for prior authorization); and 

• Copayment (the copayments for one drug option versus another). 

 The NCPDP Formulary and Benefits Standard 1.0 enables the prescriber to consider this 

information during the prescribing process, and make the most appropriate drug choice without 

extensive back-and-forth administrative activities with the pharmacy or the health plan. 

 As discussed above, the November 7, 2005 final rule (70 FR 67579) established the 

process of updating an official Part D e-prescribing standard with the recognition of ‘‘backwardcompatible’’ versions of the official standard in instances in which the user of the later version 

can accommodate users of the earlier version of the adopted standard without modification. In 

these instances, notice and comment rulemaking could be waived, and use of either the new or 

old version of the adopted standard would be considered compliant with the adopted standard 

upon the effective date of the newer version’s incorporation by reference in the Federal 

Register. This ‘‘Backward Compatible’’ version updating process allows for the standards’ 

updating/maintenance to correct technical errors, eliminate technical inconsistencies, and add 

optional functions that provide optional enhancements to the specified e-prescribing transaction 

standard. Since the adoption of the NCPDP Formulary and Benefits 1.0 standard in the Part D e-
CMS-1590-P 648 

prescribing program, NCPDP has updated its Formulary and Benefits standard. Changes were 

based upon industry feedback and business needs and ranged in complexity from creating whole 

new fields or lists within the standard to simply changing a particular field designation from 

mandatory to optional. Each time a change is made to a standard it is given a new version 

number. The current version of the Formulary and Benefits standard is version 3.0. 

One of the major improvements between version 1.0 and 3.0 involved the addition of 

Text message support for “Coverage and Copay Information,” the addition of the “Text Message 

Type (A46-1S)” field and the addition of “Optional Prior Authorization Lists.” Theses list were 

added for use in conveying prior authorization requirements. 

Other improvements included conversion of certain elements from optional to mandatory. 

Version 3.0 also provides for “Formulary Status List Headers,” which are fields that allow the 

sender to specify a default formulary status for non-listed drugs. Subsequent versions also 

allowed for the omission of “Formulary Status Detail” records when the non-listed formulary 

policies are used exclusively to convey the status of a drug on a formulary.

Changes to a standard may also involve removing fields that are not widely used in industry. 

The removed fields are often replaced by new fields that better serve the business needs of the 

industry. For example, the following items have been removed through the various updates that 

led up to version 3.0: “Classification List” and references to it (such as Drug Classification 

Information), “Coverage Information Detail – Medical Necessity (MN),” “Coverage Information 

Detail – Resource Link – Summary Level (RS),” and the Classification ID in the Cross 

Reference Detail. 

In place of these deleted fields, the following fields were added or amended to ultimately 

result in Version 3.0: The “Formulary Status existing value 2” field was changed to “On 

Formulary/Non-Preferred,” The following has been clarified from “ The file load also enables 
CMS-1590-P 649 

payers to specify a single coverage-related text message for each drug” field was changed to “A 

payer may send multiple quantity limits, step medications, text messages and resource links for 

the same drug.” 

 We have reviewed Version 3.0, and based on our findings, we have determined that 

Formulary and Benefits 3.0 maintains full functionality of the official adopted Part D eprescribing standard Formulary and Benefits 1.0, and would permit the successful 

communication of the applicable transaction with entities that continue to use Version 1.0. 

 While we would usually use the “backward compatible” waiver of notice and comment 

procedures that are described above to recognize Version 3.0 as a backward compatible version 

of the officially adopted Version 1.0, this would have to be done in an interim final rule with 

comment. As we cannot combine proposals and elements of a final rule in one rule, we are 

electing this one time to formally propose recognizing a subsequent standard as a backward 

compatible version of an adopted standard through full notice and comment rulemaking in order 

to avoid having to publish two rules contemporaneously. We therefore propose to recognize the 

use of either Version 1.0 or 3.0 as compliant with the adopted Version 1.0 effective 60 days after 

the publication of a final rule. 

 As noted above, according to the November 7, 2005 final rule (70 FR 67580), entities 

that voluntarily adopt later versions of standards that are recognized as backward compatible 

versions of the official Part D e-prescribing standard must still accommodate the earlier official 

Part D e-prescribing standard without modification. Therefore, as we are using full notice and 

comment in place of the backward compatible methodology in this one instance, we also propose 

to require users of 3.0 to support users who are still using Version 1.0 until such time as Version 

1.0 is officially retired as a Part D e-prescribing standard and Version 3.0 is adopted as the 

official Part D e-prescribing standard. 
CMS-1590-P 650 

 To effectuate these proposals, we also propose to revise §423.160(b)(5) by placing the 

existing material in a new subsection (b)(5)(i), and creating a second new subsection ((b)(5)(ii)) 

to reflect the use of Version 3.0. as a backward compatible version of the official Part D eprescribing standard [i from 60 days from the publishing of the final rule through October 31, 

2013 We seek comment on this proposal as well. 

. We also seek comment on timing and when to retire Version 1.0 as the official Part D eprescribing standard, and the proposal to adopt Formulary and Benefit Version 3.0. as the 

official Part D e-prescribing standard. 

c. Proposed Elimination of the Exemption for Non-Prescribing Providers (Long Term Care) 

 In our November 16, 2007 proposed rule (72 FR 64902 - 64906), we discussed the 

inability of NCPDP SCRIPT versions 5.0 and 8.1 to support the workflows and legal 

responsibilities in the long-term care setting, that is, entities transmitting prescriptions or 

prescription-related information where the prescriber is required by law to issue a prescription 

for a patient to a non-prescribing provider (such as a nursing facility) that in turn forwards the 

prescription to a dispenser (‘‘three-way prescribing communications’’ between facility, 

physician, and pharmacy). As such, such entities were provided with an exemption from the 

requirement to use the NCPDP SCRIPT standard in transmitting such prescriptions or 

prescription-related information. On July 1, 2010 we published an IFC (75 FR 38029) in which 

we conveyed that we would consider removing the LTC exemption when there was an NCPDP 

SCRIPT standard that could address the unique needs of long-term care settings. We noted that 

NCPDP SCRIPT Version 10.6 was available, and that we believed that it addressed the concerns 

of the LTC industry regarding their ability to successfully support their workflows when eprescribing. We solicited comments on the impact and timing of adopting version 10.6 as the 
CMS-1590-P 651 

official Part D e-prescribing standard and the removal of the long-term care facility exemption 

from the NCPDP SCIPT standard. 

 LTC enhancements were first made to the NCPDP SCRIPT version 10.2, and were 

subsequently further enhanced in subsequent versions of the SCRIPT Standard. 

 In a July 1, 2009 recommendation letter to the Secretary, 

(http://www.ncvhs.hhs.gov/090701lt.pdf) NCVHS recommended the adoption of Version 10.6, 

the retirement of Version 8.1 and the lifting of the current exemption at §423.160(a)(3)(iv) from 

the requirement to use the NCPDP SCRIPT standard for providers in long-term care settings. 

During the NCVHS testimony that preceded the recommendation letter, members of the industry 

testified that the changes that were present in NCPDP SCRIPT 10.6 created an environment 

where long-term care (LTC) facilities could carry out e-prescribing using NCPDP SCRIPT 10.6 

if it were to be adopted as the official Part D e-prescribing standard. More information on the 

testimony given to, and the recommendations given by NCVHS, can be found at the NCVHS 

Website http://www.ncvhs.hhs.gov/. 

We considered the recommendations of the industry and NCVHS and concluded that it 

would be appropriate to retire Version 8.1, adopt Version 10.6 and eliminate the LTC exemption 

from the NCPDP SCRIPT standard. Since the LTC industry currently is exempt from the 

requirement to use the NCPDP SCRIPT Version 8.1 standard, Medicare Part D e-prescribing 

operators, providers, and vendors have been utilizing proprietary e-prescribing solutions and 

interfaces in the form of electronic medication administration records and internet 

communications, which are likely not interoperable. As the use of Part D e-prescribing standards 

would promote our administrative priorities of promoting interoperability and harmonization 

among IT systems, we therefore propose to retire Version 8.1, adopt Version 10.6 and eliminate 

the current exemption at §423.160(a)(3)(iv) for entities transmitting prescriptions or prescription-
CMS-1590-P 652 

related information where the prescriber is required by law to issue a prescription for a patient to 

a non-prescribing provider (such as a nursing facility) that in turn forwards the prescription to a 

dispenser. 

We are soliciting comments on lifting the Long Term Care exemption, effective 

November 1, 2013 in conjunction with the effective date of NCPDP SCRIPT 10.6. We solicit 

comments regarding the impact of these proposed effective dates on industry and other interested 

stakeholders, and whether an earlier or later effective date should be adopted. 
CMS-1590-P 653 

IV. Technical Corrections 

A. Waiver of Deductible for Surgical Services Furnished on the Same Date as a Planned 

Screening Colorectal Cancer Test and Colorectal Cancer Screening Test Definition.

Section 4104(c) of the Affordable Care Act amended section 1833(b)(1) of the Act to 

waive the Part B deductible for colorectal cancer screening tests that become diagnostic in the 

course of the procedure or visit. Specifically, section 1833(b)(1) of the Act waives the 

deductible for colorectal screening tests regardless of the code that is billed for the establishment 

of a diagnosis as a result of the test, or the removal of tissue or other matter or other procedure 

that is furnished in connection with, as a result of, and in the same clinical encounter as a 

screening test. To implement this statutory provision, we proposed that “all surgical services 

furnished on the same date as a planned screening colonoscopy, planned flexible sigmoidoscopy, 

or barium enema be considered to be furnished in connection with, as a result of, and in the same 

clinical encounter as the screening test.” After receiving public comment, this proposal was 

finalized in the CY 2011 final rule with comment period (75 FR 73431). However, we neglected 

to amend our regulations to reflect this policy. 

When a screening test becomes a diagnostic service, practitioners are to append a 

modifier to the diagnostic procedure code that is reported instead of the HCPCS code for 

screening colonoscopy or screening flexible sigmoidoscopy or as a result of the barium enema. 

By use of this modifier, practitioners signal that the procedure meets the criteria for the 

deductible to be waived. 

To reflect this policy in our regulations, we propose to amend §410.160 Part B annual 

deductible to include colorectal screening tests that become diagnostic services in the list of 

services for which the deductible does not apply. Specifically, we propose to add a new 

§410.160(b)(8) to read, “Beginning January 1, 2011, a surgical service furnished on the same 
CMS-1590-P 654 

date as a planned colorectal cancer screening test as described in §410.37.” 

Section 103 of the BIPA amended section 1861(pp)(1)(C) of the Act to permit coverage 

of screening colonoscopies for individuals not at high risk for colorectal cancer who meet certain 

requirements. In order to conform our regulations to section 1861(pp)(1)(C) of the Act, we 

propose to modify §410.37(a)(1)(iii) to define “Screening colonoscopies” by removing the 

phrase “In the case of an individual at high risk for colorectal cancer” from this paragraph. 

We also propose to delete paragraph (g)(1) from this section since Medicare no longer 

receives claims for dates of service between January 1, 1998 and June 30, 2001, making this 

paragraph obsolete. We also propose to redesignate paragraphs (g)(2) through (g)(4) and make 

technical changes to newly redesignated paragraph (g)(1) by replacing the reference to paragraph 

(g)(4) with a reference to newly redesignated paragraph (g)(3). 
CMS-1590-P 655 

V. 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. In order 

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. 

We are soliciting public comment on each of these issues for the following sections of 

this document that contain information collection requirements (ICRs): 

A. ICRs Regarding Diagnostic X-ray Tests, Diagnostic Laboratory Tests, and Other Diagnostic

Tests: Conditions (§410.32)

Proposed §410.32(d)(2)(i) would require that the physician or qualified nonphysician 

practitioner (as defined in §410.32(a)(2)) who orders the service maintain documentation of 

medical necessity in the beneficiary’s medical record. In addition, both the medical record and 

the laboratory requisition (or order) would be required to be signed by the physician or qualified 

nonphysician practitioner who orders the service. The burden associated with these requirements 

would be the time and effort necessary for a physician or qualified nonphysician practitioner to 

sign the medical record or laboratory requisition (or order). There would also be a recordkeeping 
CMS-1590-P 656 

requirement associated with maintaining the documentation of medical necessity in the 

beneficiary medical record. While these requirements are subject to the PRA, we believe the 

associated burden is exempt from the PRA in accordance with 5 CFR 1320.3(b)(2). We believe 

that the time, effort, and financial resources necessary to comply with the aforementioned 

information collection requirements would be incurred by persons in the normal course of their 

activities and therefore considered to be usual and customary business practices. 

B. ICRs Regarding Durable Medical Equipment Scope and Conditions (§410.38(g))

 In §410.38(g), we would require (as a condition of payment for certain covered items of 

DME) that a physician must have documented and communicated to the DME supplier that the 

physician or a physician assistant (PA), a nurse practitioner (NP), or a clinical nurse specialist 

(CNS) has had a face-to-face encounter with the beneficiary no more than 90 days before the 

order is written or within 30 days after the order is written. 

 We propose that when the face-to-face encounter is performed by a physician, the 

submission of the pertinent portion(s) of the beneficiary’s medical record (portions containing 

sufficient information to document that the face-to-face encounter meets our requirements) 

would be considered sufficient and valid documentation of the face-to-face encounter when 

submitted to the supplier and made available to CMS or its agents upon request. While we 

believe that many of the practitioners addressed in this proposed rule are already conducting a 

needs assessment and evaluating or treating the beneficiary for conditions relevant to the covered 

item of DME, this proposed rule may require some changes in their procedures to ensure that 

their documentation fulfills Medicare's regulatory requirements. Suppliers should already be 

receiving written orders and documentation to support the appropriateness of certain items of 

DME. 

To promote the authenticity and comprehensiveness of the written order and as part of 
CMS-1590-P 657 

our efforts to reduce the risk of waste, fraud, and abuse, we propose that as a condition of 

payment a written order must include: (1) the beneficiaries’ name; (2) the item of DME ordered; 

(3) prescribing practitioner NPI; (4) the signature of the prescribing practitioner; (5) the date of 

the order; (6) the diagnosis; and (7) necessary proper usage instructions, as applicable. 

In order to determine costs associated with the impact we utilized the Bureau of Labor 

Statistics mean hourly rates for the professional, analyzed for the year that the original data was 

received. The hourly rate for a physician, including fringe benefits and overhead is estimated at 

$118 per hour. The hourly rate, including fringe benefits and overhead, for a NP, PA, CNS is 

estimated at $55 per hour. The hourly rate for administrative assistant, including fringe benefits 

and overhead, is estimated at $23 per hour. 

Physicians are now required to document the face-to-face encounter if it was performed 

by a PA, NP, or CNS. In order to allow payment for this documentation, a G code is established 

for this service. There are approximately 10 million DME users and it was assumed that roughly 

5 percent of face-to-face encounters are actually performed by these other provider types, 

thereby requiring documentation of the encounter. Therefore, it was assumed that about 500,000 

of these documentation services would be billed. We estimate the time for a physician to review 

each one of these encounters that results in an order is 10 minutes. Therefore, we estimate that 

the physician documentation burden to review and document when a PA, NP or CNS performed 

the face-to-face encounter in year 1 would be nearly 83,333 hours and a total of 700,000 million 

hours over 5 years. The associated cost in year 1 is nearly $9.8 million and over 5 years has 

associated costs of nearly $82.6 million based on the growth rate of the Medicare population. 

The increase is slightly more than five-fold because the number of Medicare beneficiaries would 

increase over time. 
CMS-1590-P 658 

TABLE 78: Physician Time to Document Occurrence of a Face-to-Face Encounter 

 Year 1 5 Years 

Number of claims affected 500,000 4,200,000

Time for physician review of each claim 10 min 10 min 

Total Time 83,333 hours 

700,000

hours 

Estimated Total Cost (Hours times $118) $ 9,833,333 $ 82,600,000 

We assume it will take 3 minutes for a PA, NP, or CNS to prepare the medical record for 

the review of the face-to-face encounter. For the 500,000 orders used in the previous estimate, 

this creates a total of 25,000 hours at a cost of about $1.4 million in year 1 and nearly 210,000 

hours over 5 years at a cost of nearly $11.6 million based on the growth rate of the Medicare 

population. Though consistent with previous estimates, we believe that using a PA, NP, or CNS 

hourly rate creates a high burden impact estimate since most of these tasks would more than 

likely be completed by administrative personnel. We welcome comments on the appropriateness 

of these estimates. 

TABLE 79: Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist Time 

 Year 1 5 Years 

Number of claims affected 500,000 4,200,000

Time for PAs, NPs, or CNSs to gather and provide each claim 3 min 3 min

Total Time 25,000 hours 210,000 hours 

Estimated Total Cost (Hours times $55) $ 1,375,000.00 11,550,000

This proposed rule would create only a minimal change in the normal course of business 

activities in regards to recordkeeping. Although we believe the documentation of a needs 

assessment, evaluation, and or treatment of a beneficiary for a condition relevant to an item of 

DME is a common practice, it is possible that some practitioners may not be documenting the 

results of all encounters; and therefore, there may be additional impact for some practitioners. 

This regulation requires that the supplier have access to the documentation of the face-toface encounter, which is required when CMS conducts an audit. CMS already accounts for the 
CMS-1590-P 659 

audit burden associated with the exchange of documentation for claims subject to prepayment 

review (approved under OCN 0938-0969). As a business practice we recognize that some 

suppliers may receive the documentation of the face-to-face for all applicable claims, voluntarily. 

 We believe that the requirements expressed in this proposed rule meet the utility and 

clarity standards. We welcome comment on this assumption and on ways to minimize the 

burden on affected parties. The proposed recordkeeping requirement in §410.38(g)(5) and the 

requirement to maintain and make the supplier’s order/additional documentation available to 

CMS upon request is subject to the PRA, but we believe that these requirements are usual and 

customary business practices as defined in 5 CFR 1320.3(b)(2) and, therefore, the associated 

burden is exempt from the PRA. 

C. ICRs Regarding Physician Quality Reporting System – Definitions (§414.90(b))

While §414.90(b) contains information collection requirements regarding the input process 

and the endorsement of consensus-based quality measures, this rule would not revise any of the 

information collection requirements or burden estimates that are associated with those 

provisions. All of the requirements and burden estimates are currently approved by OMB under 

OCN 0938-1083, and are not subject to additional OMB review under the authority of the 

Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.). 

D. ICRs Regarding Physician Quality Reporting System – Use of Consensus-based Quality 

Measures (§ 414.90(e))

We are proposing to revise §414.90(e), redesignated as to broadly define our use of 

consensus-based quality measures. The current regulation at §414.90(e) states that we will 

publish a final list of measures every year. However, we are proposing measures for 2013 and 

beyond this year . 

While §414.90(e) contains information collection requirements regarding the input process 
CMS-1590-P 660 

and the endorsement of consensus-based quality measures, this rule would not revise any of the 

information collection requirements or burden estimates that are associated with those 

provisions. All of the requirements and burden estimates are currently approved by OMB under 

OCN 0938-1083, and are not subject to additional OMB review under the authority of the 

Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.). 

E. ICRs Regarding Physician Quality Reporting System – Requirements for the Incentive 

Payments (§ 414.90(g))

While §414.90(g) contains information collection requirements regarding the PQRS 

incentive payments, this rule would not revise any of the information collection requirements or 

burden estimates that are associated with those provisions. All of the requirements and burden 

estimates are currently approved by OMB under OCN 0938-1083, and are not subject to 

additional OMB review under the authority of the Paperwork Reduction Act of 1995 (44 U.S.C. 

3501 et seq.). 

F. ICRs Regarding Physician Quality Reporting System – Requirements for the Payment 

Adjustments (§414.90)

 While §414.90 contains information collection requirements regarding the PQRS 

payment adjustments, this rule would not revise any of the information collection requirements 

or burden estimates that are associated with those provisions, except for the proposed criteria for 

reporting via claims for the 2015 and 2016 PQRS payment adjustments and the provisions that 

would allow the administrative claims reporting option. Otherwise, all of the requirements and 

burden estimates are currently approved by OMB under OCN 0938-1083 and are not subject to 

additional OMB review under the authority of the Paperwork Reduction Act of 1995 (44 U.S.C. 

3501 et seq.). 

 With respect to the proposed reporting criteria for the 2015 and 2016 PQRS payment 
CMS-1590-P 661 

adjustments using the claims-based reporting mechanism, we note below that we anticipate that 

approximately 320,000 eligible professionals would use the claims-based reporting mechanism 

for CYs 2013 and 2014. This is a difference of 120,000 from the 200,000 that participated in 

PQRS using the claims-based reporting mechanism in 2010. We believe that these 120,000 

eligible professional would use the 2015 and 2016 PQRS payment adjustment claims-based 

payment adjustment criteria to meet the criteria for satisfactory reporting for the 2015 and 2016 

payment adjustments. 

We estimate the cost for an eligible professional and group practices to review the list of 

PQRS quality measures or measures group, identify the applicable measures or measures group 

for which they can report the necessary information, incorporate reporting of the selected 

measures or measures group into the office work flows, and select a PQRS reporting option to be 

approximately $200 per eligible professional ($40 per hour x 5 hours). Based on our experience 

with the Physician Voluntary Reporting Program PVRP, we continue to estimate that the time 

needed to perform all the steps necessary to report each measure (that is, reporting the relevant 

quality data code(s) for a measure) on claims will ranges from 15 seconds (0.25 minutes) to over 

12 minutes for complicated cases and/or measures, with the median time being 1.75 minutes. At 

an average labor cost of $40/hour per practice, the cost associated with this burden would range 

from $0.17 in labor to about $8.00 in labor time for more complicated cases and/or measures, 

with the cost for the median practice being $1.67. 

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 are 

proposing to reduce the required reporting rate by over one-third to 50 percent, then for purposes 
CMS-1590-P 662 

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 or eligible professional in a group practice associated with 

claims-based reporting would range from 4.5 minutes (0.25 minutes per measure x 3 measures x 

6 cases per measure) to 180 minutes (12 minutes per measure x 3 measures x 6 cases per 

measure), with the burden to the median practice being 31.5 minutes (1.75 minutes per measure 

x 3 measures x 6 cases). We estimate the total annual reporting cost per eligible professional or 

eligible professional in a group practice associated with claims-based reporting would range 

from $3.06 ($0.17 per measure x 3 measures x 6 cases per measure) to $144.00 ($8.00 per 

measure x 3 measures x 6 cases per measure), with the cost to the median practice being $30.06 

per eligible professional ($1.67 per measure x 3 measures x 6 cases per measure). 

 With respect to reporting using the administrative claims reporting option, we estimate 

that the burden associated with reporting using the administrative claims option is the time and 

effort associated with reporting. We note that the burden for eligible professionals and group 

practices using the administrative claims-based reporting mechanism 

G. Summary of Annual Burden Estimates for Codified Requirements (Proposed)

TABLE 80: Summary of Annual Burden Estimates 

Regulation 

section(s) 

OCN Respondents Responses Burden per 

response (hr) 

Total 

burden (hr) 

410.38(g) 

re: Physician 

0938-New 500,000 500,000 10 min 83,333 
CMS-1590-P 663 

410.38(g) 

re: PA, NP, 

or CNS 

0938-New 500,000 500,000 3 min 25,000 

414.90(h) 0938-1083 120,000 120,000 

(120,000 

responses x 1 

measure) 

0.5 (31.5 

minutes – the 

median) 

60,000 

H. Additional Information Collection Requirements

While this proposed rule would impose collection of information requirements that are 

set out in the regulatory text (see above), this rule also sets out information collection 

requirements that are set out only in the preamble. Following is a discussion of the preamblespecific information collections, some of which have already received OMB approval. 

1. Part B Drug Payment 

The discussion of average sales price (ASP) issues in section XXX of this proposed rule 

does not contain any new information collection requirements with respect to payment for 

Medicare Part B drugs and biologicals under the ASP methodology. Drug manufacturers are 

required to submit ASP data to us on a quarterly basis. The ASP reporting requirements are set 

forth in section 1927(b) of the Act. The burden associated with this requirement is the time and 

effort required by manufacturers of Medicare Part B drugs and biologicals to calculate, record, 

and submit the required data to CMS. All of the requirements and burden estimates are currently 

approved by OMB under OCN 0938-0921, and are not subject to additional OMB review under 

the authority of the Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.). 

2. Physician Quality Reporting System (PQRS) 

The preamble of this proposed rule discusses the background of the PQRS, provides 

information about the proposed measures and reporting mechanisms that would be available to 

eligible professionals and group practices who choose to participate in the 2013 and 2014 PQRS, 

and provides the proposed criteria for satisfactory reporting in CYs 2013 and 2014 (for the 2013 
CMS-1590-P 664 

and 2014 PQRS incentives and the 2015 and 2016 PQRS payment adjustments). 

a. Participation in the 2013 and 2014 PQRS 

 According to the 2010 Reporting Experience Report, a total of $391,635,495 in PQRS 

incentives was paid by CMS for the 2010 program year, which encompassed 168,843 individual 

eligible professionals. In 2010, eligible professionals earned a 2.0 percent incentive (i.e., a bonus 

payment equal to 2.0 percent of the total allowed part B charges for covered professional 

services under the PFS furnished by the eligible professional in the reporting period) for 

satisfactory reporting under PQRS. For 2013 and 2014, eligible professionals can earn a 0.5 

percent incentive for satisfactory reporting, a reduction of 1.5 percent from 2010. Therefore, 

based on 2010, we would expect that approximately $97 million (approximately 1⁄4 of 

$391,635,495) in incentive payments would be distributed to eligible professionals who 

satisfactorily report. However, we expect that, due to the implementation of payment 

adjustments beginning in 2015, participation in PQRS would rise to approximately 300,000 

eligible professionals and 400,000 eligible professionals in 2013 and 2014 respectively. 

 The average incentive distributed to each eligible professional in 2010 was $2,157. 

Taking into account the 1.5 percent incentive reduction from 2.0 percent in 2010 to 0.5 percent 

in 2013 and 2014, we estimate that the average amount per eligible professional earning an 

incentive in 2013 and 2014 would be $539. Therefore, we estimate that we would distribute 

approximately $162 million ($539 x 300,000 eligible professionals) and $216 million ($539 x 

400,000 eligible professionals) in incentive payments in 2013 and 2014, respectively. We 

believe these incentive payments will help offset the cost to eligible professionals participating in 

PQRS for the applicable year. Please note that, beginning 2015, incentive payments for 

satisfactory reporting in PQRS will cease and payment adjustments for not satisfactorily 

reporting will commence. 
CMS-1590-P 665 

 We note that the total burden associated with participating in PQRS is the time and effort 

associated with indicating intent to participate in PQRS, if applicable, and submitting PQRS 

quality measures data. When establishing these burden estimates, we assume the following: 

● The requirements for reporting for PQRS 2013 and 2014 incentives and 2015 and 

2016 payment adjustments would be established as proposed in this 2013 Medicare PFS 

proposed rule. 

● For an eligible professional or group practice using the claims, registry, or EHR-based 

reporting mechanisms, that the eligible professional or group practice would report on 3 

measures. 

● With respect to labor costs, we believe that a billing clerk would handle the 

administrative duties associated with participating, while a computer analyst would handle duties 

related to reporting PQRS quality measures. According to the Bureau of Labor Statistics, the 

mean hourly wage for a billing clerk is approximately $16/hour whereas the mean hourly wage 

for a computer analyst is approximately $40/hour. 

b. Burden Estimate on Participation in the CYs 2013 and 2014 PQRS – New Individual Eligible 

Professionals: Preparation 

 For an eligible professional who wishes to participate in PQRS as an individual, the 

eligible professional need not indicate his/her intent to participate. Instead, the eligible 

professional may simply begin reporting quality measures data. Therefore, these burden 

estimates for individual eligible professionals participating in PQRS are based on the reporting 

mechanism the individual eligible professional chooses. However, we believe a new eligible 

professional or group practice would spend 5 hours—which includes 2 hours to review PQRS 

measures list, review the various reporting options, and select a reporting option and measures on 

which to report and 3 hours to review the measure specifications and develop a mechanism for 
CMS-1590-P 666 

incorporating reporting of the selected measures into their office work flows. Therefore, we 

believe that the initial administrative costs associated with participating in PQRS would be 

approximately $80 ($16/hour x 5 hours). 

c. Burden Estimate on Participation in the 2013 and 2014 PQRS via the Claims-based Reporting 

Mechanism – Individual Eligible Professionals 

In 2010, approximately 200,000 of the roughly 245,000 eligible professionals (or 84 

percent) of eligible professionals used the claims-based reporting mechanism. We believe that 

although the number of eligible professionals or group practices using the claims-based reporting 

mechanism will increase in CYs 2013 and 2014, we anticipate that the percentage of eligible 

professionals or group practices using the claims-based reporting mechanism will decrease 

slightly as eligible professionals and group practices transition towards using the EHR-based 

reporting mechanism. Therefore, although we estimate that the participation rate for PQRS will 

double from participation rates in 2010, we note that, although we believe the claims-based 

reporting mechanism will be the most widely used, the percentage of PQRS participants using 

the claims-based reporting mechanism will decrease as we anticipate that more eligible 

professionals would use the registry and EHR-based reporting mechanisms. For these reasons, 

we estimate that approximately 320,000 eligible professionals, whether participating individually 

or in a group practice, will participate in PQRS in CY 2014. 

With respect to an eligible professional who participates in PQRS via claims, the eligible 

professional must gather the required information, select the appropriate quality data codes 

(QDCs), and include the appropriate QDCs on the claims they submit for payment. PQRS will 

collect QDCs as additional (optional) line items on the existing HIPAA transaction 837-P and/or 

CMS Form 1500 (OCN 0938-0999). Based on our experience with Physician Voluntary 

Reporting Program PVRP, we continue to estimate that the time needed to perform all the steps 
CMS-1590-P 667 

necessary to report each measure via claims would range from 0.25 minutes to 12 minutes, 

depending on the complexity of the measure. Therefore, the time spent reporting 3 measures 

would range from 0.75 minutes to 36 minutes. Using an average labor cost of $40/hour, we 

estimate that time cost of reporting for an eligible professional via claims will range from $0.50 

(0.75 minutes x $40/hour) to $24.00 (36 minutes x $40/hour) per reported case. With respect to 

how many cases an eligible professional would report when using the claims-based reporting 

mechanism, we proposed that an eligible professional would need to report on 50 percent of the 

eligible professional’s applicable cases. The actual number of cases on which an eligible 

professional will report will vary depending on the number of the eligible professional’s 

applicable cases. However, in prior years, when the reporting threshold was 80 percent, we 

found that the median number of reporting cases for each measure was 9. Since we are 

proposing to reduce the reporting threshold to 50 percent, we estimate that the average number of 

reporting cases for each measure would be reduced to 6. Based on these estimates, we estimate 

that the total cost of reporting for an eligible professional choosing the claims-based reporting 

mechanism would range from ($0.50/per reported case x 6 reported cases) $3.00 to 

($24.00/reported case x 6 reported cases) $144. 

 We note that, for the 2015 and 2016 PQRS payment adjustments, we are proposing an 

administrative claims reporting option for eligible professionals and group practices. The burden 

associated with reporting using the administrative claims reporting option is the time and effort 

associated with using this option. To submit quality measures data for PQRS using the 

administrative claims reporting option, an eligible professional or group practice would need to 

(1) register as an administrative claims reporter for the applicable payment adjustment and (2) 

report quality measures data. With respect to registration, we believe it would take 

approximately 2 hours to register for to participate in PQRS as an administrative claims reporter. 
CMS-1590-P 668 

Therefore, we estimate that the cost of undergoing the GPRO selection process will be ($16/hour 

x 2 hours) $32. With respect to reporting, we note that any burden associated with reporting 

would be negligible, as an eligible professional or group practice would not be required to attach 

reporting G-codes on the claims they submit. Rather, CMS would bear the burden of reporting 

with respect to selecting which measures to report. We note that there would be no additional 

burden on the eligible professional or group practice to submit these claims, as the eligible 

professional or group practice would have already submitted these claims for reimbursement 

purposes. 

d. Burden Estimate on Participation in the CYs 2013 and 2014 PQRS via the Registry-based or 

EHR-based Reporting Mechanism 

 In 2010, approximately 40,000 of the roughly 245,000 eligible professionals (or 16 

percent) of eligible professionals used the registry-based reporting mechanism. We believe the 

number of eligible professionals and group practices using the registry based reporting 

mechanism will remain the same, as eligible professionals use registries for functions other than 

PQRS and therefore would obtain a registry solely for PQRS reporting by CY 2014. In 2010, 

only 14 of the roughly 245,000 eligible professionals (or >1 percent) of eligible professionals 

used the EHR-based reporting mechanism. We believe the number of eligible professionals and 

group practices using the EHR-based reporting mechanism will increase as eligible professionals 

become more familiar with EHR products. In particular, we believe eligible professionals and 

group practices will transition from using the claims-based to the EHR-based reporting 

mechanisms. We estimate that approximately 40,000 eligible professionals (4 percent), whether 

participating as an individual or part of a group practice, will use the EHR-based reporting 

mechanism in CY 2014. 
CMS-1590-P 669 

 With respect to an eligible professional or group practice who participates in PQRS via a 

qualified registry, direct EHR product, or EHR data submission vendor product, we believe there 

would be little to no burden associated for an eligible professional to report PQRS quality 

measures data to CMS, because the selected reporting mechanism submits the quality measures 

data for the eligible professional. While we note that there may be start-up costs associated with 

purchasing a qualified registry, direct EHR product, or EHR data submission vendor, we believe 

that an eligible professional or group practice would not purchase a qualified registry, direct 

EHR product, or EHR data submission vendor product solely for the purpose of reporting PQRS 

quality measures. Therefore, we have not included the cost of purchasing a qualified registry, 

direct EHR, or EHR data submission vendor product in our burden estimates. 

e. Burden Estimate on Participation in the CYs 2013 and 2014 PQRS – Group Practices 

 Unlike eligible professionals who choose to report individually, we note that we are 

proposing that eligible professionals choosing to participate as part of a group practice under the 

GPRO would need to indicate their intent to participate in PQRS as a GPRO. The total burden 

for group practices who submit PQRS quality measures data via the GPRO web-interface would 

be the time and effort associated with submitting this data. To submit quality measures data for 

PQRS, a group practice would need to (1) be selected to participate in the PQRS GPRO and (2) 

report quality measures data. With respect to the administrative duties for being selected to 

participate in PQRS as a GPRO, we believe it would take approximately 6 hours – including 2 

hours to decide to participate in PQRS as a GPRO, 2 hours to self-nominate, and 2 hours to 

undergo the vetting process with CMS officials – for a group practice to be selected to participate 

in PQRS GPRO for the applicable year. Therefore, we estimate that the cost of undergoing the 

GPRO selection process will be ($16/hour x 6 hours) $96. 
CMS-1590-P 670 

 With respect to reporting PQRS quality measures using the GPRO web-interface, the 

total reporting burden is the time and effort associated with the group practice submitting the 

quality measures data (that is, completed the data collection interface). Based on burden 

estimates for the PGP demonstration, which uses the same data submission methods, we estimate 

the burden associated with a group practice completing the data collection interface would be 

approximately 79 hours. Therefore, we estimate that the report cost for a group practice to 

submit PQRS quality measures data for an applicable year would be ($40/hour x 79 hours) 

$3,160. 

 Eligible professionals who wish to qualify for an additional 0.5 percent Maintenance of 

Certification Program incentive will need to “more frequently” than is required to qualify for or 

maintain board certification status participate in a qualified Maintenance of Certification 

Program for 2012 and successfully complete a qualified Maintenance of Certification Program 

practice assessment for the applicable year. Although we understand that there is a cost 

associated with participating in a Maintenance of Certification Board, we believe that most of the 

eligible professionals attempting to earn this additional incentive would already be enrolled in a 

Maintenance of Certification Board for reasons other than earning the additional Maintenance of 

Certification Program incentive. Therefore, the burden to earn this additional incentive will 

depend on what a certification board establishes as “more frequently” and the time needed to 

complete the practice assessment component. We expect that the amount of time needed to 

complete a qualified Maintenance of Certification Program practice assessment would be spread 

out over time since a quality improvement component is often required. With respect to the 

practice assessment component, according to an informal poll conducted by ABMS in 2012, the 

time an individual spends to complete the practice assessment component of the Maintenance of 

Certification ranges from 8-12 hours. 
CMS-1590-P 671 

f. Burden Estimate on Vendor Participation in the CYs 2013 and 2014 PQRS 

 Aside from the burden of eligible professionals and group practices participating in 

PQRS, we believe that registry and EHR vendor products incur costs associated with 

participating in PQRS. 

 Based on the number of registries that have self-nominated to become a qualified PQRS 

registry in prior program years, we estimate that approximately 50 additional registries would 

self-nominate to be considered a qualified registry for PQRS. With respect to qualified 

registries, the total burden for qualified registries who submit PQRS quality measures data would 

be the time and effort associated with submitting this data. To submit quality measures data for 

the proposed PQRS program years, a registry would need to (1) become qualified for the 

applicable year and (2) report quality measures data on behalf of its eligible professionals. With 

respect to administrative duties related to the qualification process, we estimate that it would take 

a total of 10 hours – including 1 hour to complete the self-nomination statement, 2 hours to 

interview with CMS, 2 hours to calculate numerators, denominators, and measure results for 

each measure the registry wishes to report using a CMS-provided measure flow, and 5 hours to 

complete an XML submission – to become qualified to report PQRS quality measures data. 

Therefore, we estimate that it would cost a registry approximately ($16.00/hour x 10 hours) $160 

to become qualified to submit PQRS quality measures data on behalf of its eligible professionals. 

With respect to the reporting of quality measures data, the burden associated with 

reporting is the time and effort associated with the registry calculating quality measures results 

from the data submitted to the registry by its eligible professionals, submitting numerator and 

denominator data on quality measures, and calculating these measure results. We believe, 

however, that registries already perform these functions for its eligible professionals irrespective 

of participating in PQRS. Therefore, we believe there is little to no additional burden associated 
CMS-1590-P 672 

with reporting PQRS quality measures data. Whether there is any additional reporting burden 

will vary with each registry, depending on the registry’s level of savvy with submitting quality 

measures data for PQRS. 

 With respect to EHR products, the total burden for direct EHR products and EHR data 

submission vendors who submit PQRS quality measures data will be the time and effort 

associated with submitting this data. To submit quality measures data for the proposed PQRS 

program years, a direct EHR product or EHR data submission vendor would need to report 

quality measures data on behalf of its eligible professionals. Please note that since we are 

proposing not to continue to require direct EHR products and EHR data submission vendors to 

become qualified to submit PQRS quality measures data, there is no burden associated with 

qualification of direct EHR products and EHR data submission vendor products. With respect to 

reporting quality measures data, we believe the burden associated with the EHR vendor 

programming its EHR product(s) to extract the clinical data that the eligible professional would 

need to submit to CMS will depend on the vendor’s familiarity with PQRS and the vendor’s 

system and programming capabilities. Since we believe that an EHR vendor would be 

submitting data for reasons other than reporting under PQRS, we believe there would be no 

additional burden for an EHR vendor to submit quality measures data for PQRS reporting. 

g. Summary of Burden Estimates on Participation in the 2013 and 2014 PQRS - Eligible 

Professionals and Vendors 

TABLE 81: Estimated Costs for Reporting PQRS Quality Measures Data for Eligible 

Professionals 

 Estimated 

Hours 

Estimated 

Cases 

Number of 

Measures 

Hourly 

Rate 

Total 

Cost 

Individual Eligible Professional 

(EP): Preparation 

5.0 1 N/A $16 $80 

Individual EP: Claims 0.2 6 3 $40 $144 

Individual EP: Administrative 

Claims 

2 1 N/A $16 $32 

Individual EP: Registry N/A 1 N/A N/A Minimal
CMS-1590-P 673 

Individual EP: EHR N/A 1 N/A N/A Minimal

Group Practice: Self-Nomination 6.0 1 N/A $16 $96 

Group Practice: Reporting 79 1 N/A $40 $3,160 

TABLE 82: Estimated Costs to Vendors to Participate in PQRS 

 Estimated Hours Hourly Rate Total Cost 

Registry: Self-Nomination 10 $160 $160 

EHR: Programming 0 $0 0 

3. Electronic Prescribing (eRx) Incentive Program 

 The requirements for the eRx Incentive Program for 2012—2014 were established in the 

CY 2012 Medicare PFS final rule. Although we are making proposals related to the eRx 

Incentive Program in the CY 2013 Medicare PFS, these proposals have no additional burden or 

impact on the public. Therefore, this rule would not revise the requirements or burden estimates 

approved by OMB under OCN: 0938-1083. 

4. Physician Quality Reporting System-Medicare EHR Incentive Pilot 

 The Physician Quality Reporting System-Medicare EHR Incentive Pilot is a Pilot that 

provides a method whereby an eligible professional participating in both PQRS and Medicare 

EHR Incentive Program may submit one set of data and satisfy the reporting requirements for 

both programs. We believe any burden or impact associated with the Pilot would be absorbed in 

the burden and impact estimates provided for PQRS (OCN: 0938-1083) and the EHR Incentive 

Program. 

I. Submission of PRA-Related Comments

If you comment on these information collection and recordkeeping requirements, please 

do either of the following: 

 1. Submit your comments electronically as specified in the ADDRESSES section of this 

proposed rule; or 
CMS-1590-P 674 

 2. Submit your comments to the Office of Information and Regulatory Affairs, Office of 

Management and Budget, 

 Attention: CMS Desk Officer, [CMS-1590-P] 

 Fax: (202) 395-6974; or 

 Email: OIRA_submission@omb.eop.gov. 

VI. 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. 
CMS-1590-P 675 

VII. Regulatory Impact Analysis 

A. Statement of Need

 This proposed rule is necessary in order to make payment and policy changes under the 

Medicare PFS and to make required statutory changes under the Middle Class Tax Relief and 

Job Creation Act of 2012 (MCTRJCA), the Affordable Care Act, and other statutory changes. 

This proposed rule also is necessary to make changes to Part B drug payment policy and other 

related 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, 2012), 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 
CMS-1590-P 676 

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 and most other providers and suppliers are small entities, either by 

nonprofit status or by having revenues of $7.0 million to $34.5 million in any 1 year (for details 

see the SBA's Website at http://www.sba.gov/content/table-small-business-size-standards (refer 

to the 620000 series)). Individuals and States are not included in the definition of a small entity. 

The RFA requires that we analyze regulatory options for small businesses and other 

entities. We prepare a regulatory flexibility analysis unless we certify that a rule would not have 

a significant economic impact on a substantial number of small entities. The analysis must 

include a justification concerning the reason action is being taken, the kinds and number of small 

entities the rule affects, and an explanation of any meaningful options that achieve the objectives 

with less significant adverse economic impact on the small entities. 

For purposes of the RFA, physicians, NPPs, and suppliers including IDTFs are 

considered small businesses if they generate revenues of $10 million or less based on SBA size 

standards. Approximately 95 percent of physicians are considered to be small entities. There are 

over 1 million physicians, other practitioners, and medical suppliers that receive Medicare 

payment under the PFS. 

Because we acknowledge that many of the affected entities are small entities, the analysis 

discussed throughout the preamble of this proposed rule constitutes our regulatory flexibility 

analysis for the remaining provisions and addresses comments received on these issues. 

In addition, section 1102(b) of the Act requires us to prepare a regulatory impact analysis 

if a rule may have a significant impact on the operations of a substantial number of small rural 

hospitals. This analysis must conform to the provisions of section 603 of the RFA. For purposes 

of section 1102(b) of the Act, we define a small rural hospital as a hospital that is located outside 
CMS-1590-P 677 

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 2012, that threshold is approximately $139 million. 

This proposed rule would have no consequential spending effect 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 
CMS-1590-P 678 

conflict with this proposed rule. The relevant sections of this proposed rule contain a description 

of significant alternatives if applicable. 

C. Relative Value Unit (RVU) Impacts 

1. Resource-Based Work, PE, and Malpractice 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 BN. 

Our estimates of changes in Medicare revenues for PFS services compare payment rates 

for CY 2012 with proposed payment rates for CY 2013 using CY 2011 Medicare utilization as 

the basis for the comparison. To the extent that there are year-to-year changes in the volume and 

mix of services furnished by physicians, the actual impact on total Medicare revenues will be 

different from those shown in Tables 83 (CY 2013 PFS Proposed Rule Estimated Impact on 

Total Allowed Charges by Specialty) and 84 (CY 2013 PFS Proposed Rule Estimated Impact on 

Total Allowed Charges by Specialty by Selected Proposal). The payment impacts reflect 

averages for each specialty based on Medicare utilization. The payment impact for an individual 

physician would be different from the average and would depend on the mix of services the 

physician furnishes. The average change in total revenues would be less than the impact 

displayed here because physicians furnish services to both Medicare and non-Medicare patients 

and specialties may receive substantial Medicare revenues for services that are not paid under the 

PFS. For instance, independent laboratories receive approximately 85 percent of their Medicare 

revenues from clinical laboratory services that are not paid under the PFS. 

Tables 83 and 84 show the payment impact on PFS services. We note that these impacts 

do not include the effect of the January 2013 conversion factor changes under current law. The 
CMS-1590-P 679 

annual update to the PFS conversion factor 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. By law, we are required to apply these updates in accordance with section 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. We provide our most 

recent estimate of the SGR and physician update for CY 2013 on our website at 

http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/SustainableGRatesConFact/index.html?redirect=/SustainableGRatesConFact/. 

The following is an explanation of the information represented in Table 83: 

● Column A (Specialty): The Medicare specialty code as reflected in our 

physician/supplier enrollment files. 

● Column B (Allowed Charges): The aggregate estimated PFS allowed charges for the 

specialty based on CY 2011 utilization and CY 2012 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 
CMS-1590-P 680 

furnished by physicians, practitioners, and suppliers within a specialty to arrive at the total 

allowed charges for the specialty. 

● Column C (Impact of Work and Malpractice (MP) RVU Changes): This column 

shows the estimated CY 2013 impact on total allowed charges of the changes in the work and 

malpractice RVUs, including the impact of changes due to potentially misvalued codes. 

● Column D (Impact of PE RVU Changes): This column shows the estimated CY 2013 

impact on total allowed charges of the changes in the PE RVUs. 

● Column E (Combined Impact): This column shows the estimated CY 2013 combined 

impact on total allowed charges of all the changes in the previous columns. 

TABLE 83: CY 2013 PFS Proposed Rule Estimated Impact on Total Allowed Charges by 

Specialty* 

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

 Specialty Allowed 

Charges 

(mil) 

Impact of 

Work and 

MP RVU 

Changes 

Impact of 

PE RVU 

Changes 

Combined 

Impact 

TOTAL $ 86,000 0% 0% 0% 

01-ALLERGY/ IMMUNOLOGY $ 198 -1% 1% 0% 

02-ANESTHESIOLOGY $ 1,970 -1% -3% -3% 

03-CARDIAC SURGERY $ 366 -1% -2% -2% 

04-CARDIOLOGY $ 6,568 -1% -2% -3% 

05-COLON AND RECTAL SURGERY $ 153 -1% 1% 1% 

06-CRITICAL CARE $ 261 -1% 0% 0% 

07-DERMATOLOGY $ 3,008 -1% 0% 0% 

08-EMERGENCY MEDICINE $ 2,819 -1% 0% -1% 

09-ENDOCRINOLOGY $ 434 -1% 1% 1% 

10-FAMILY PRACTICE $ 5,879 3% 4% 7% 

11-GASTROENTEROLOGY $ 1,885 -1% 0% 0% 

12-GENERAL PRACTICE $ 579 -1% 1% 0% 

13-GENERAL SURGERY $ 2,261 -1% 0% 0% 

14-GERIATRICS $ 217 1% 3% 4% 

15-HAND SURGERY $ 134 -1% 0% 0% 

16-HEMATOLOGY/ ONCOLOGY $ 1,900 -1% 0% -1% 

17-INFECTIOUS DISEASE $ 623 -1% 1% 0% 

18-INTERNAL MEDICINE $ 11,058 2% 3% 5% 

19-INTERVENTIONAL PAIN MGMT $ 534 -1% 0% -1% 

20-INTERVENTIONAL RADIOLOGY $ 203 -1% -2% -3% 

21-MULTISPECIALTY CLINIC/OTHER PHY $ 202 -1% -1% -1% 

22-NEPHROLOGY $ 2,065 -1% 0% -1% 
CMS-1590-P 681 

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

 Specialty Allowed 

Charges 

(mil) 

Impact of 

Work and 

MP RVU 

Changes 

Impact of 

PE RVU 

Changes 

Combined 

Impact 

23-NEUROLOGY $ 1,601 -1% 2% 1% 

24-NEUROSURGERY $ 681 -1% 0% -1% 

25-NUCLEAR MEDICINE $ 49 -1% -3% -3% 

27-OBSTETRICS/ GYNECOLOGY $ 698 -1% 0% 1% 

28-OPHTHALMOLOGY $ 5,621 -1% 1% 1% 

29-ORTHOPEDIC SURGERY $ 3,622 -1% 0% -1% 

30-OTOLARNGOLOGY $ 1,070 -1% 1% 0% 

31-PATHOLOGY $ 1,185 -1% -1% -2% 

32-PEDIATRICS $ 64 2% 3% 5% 

33-PHYSICAL MEDICINE $ 990 -1% 1% 1% 

34-PLASTIC SURGERY $ 351 -1% 0% 0% 

35-PSYCHIATRY $ 1,149 -1% 0% 0% 

36-PULMONARY DISEASE $ 1,691 -1% 1% 0% 

37-RADIATION ONCOLOGY $ 1,983 -1% -14% -14% 

38-RADIOLOGY $ 4,791 -1% -3% -4% 

39-RHEUMATOLOGY $ 545 -1% 0% 0% 

40-THORACIC SURGERY $ 340 -1% -1% -2% 

41-UROLOGY $ 1,909 -1% -1% -2% 

42-VASCULAR SURGERY $ 882 -1% -2% -3% 

43-AUDIOLOGIST $ 57 -1% -4% -5% 

44-CHIROPRACTOR $ 738 -1% 1% 1% 

45-CLINICAL PSYCHOLOGIST $ 567 -1% -2% -3% 

46-CLINICAL SOCIAL WORKER $ 400 -1% -2% -3% 

47-DIAGNOSTIC TESTING FACILITY $ 875 -1% -7% -8% 

48-INDEPENDENT LABORATORY $ 1,064 -1% -1% -1% 

49-NURSE ANES / ANES ASST $ 1,142 -1% -3% -4% 

50-NURSE PRACTITIONER $ 1,606 1% 3% 5% 

51-OPTOMETRY $ 1,048 -1% 2% 1% 

52-ORAL/MAXILLOFACIAL SURGERY $ 44 -1% 1% 0% 

53-PHYSICAL/OCCUPATIONAL THERAPY $ 2,613 -1% 3% 3% 

54-PHYSICIAN ASSISTANT $ 1,219 1% 2% 3% 

55-PODIATRY $ 1,898 -1% 2% 1% 

56-PORTABLE X-RAY SUPPLIER $ 104 -1% 2% 2% 

57-RADIATION THERAPY CENTERS $ 71 -1% -18% -19% 

98-OTHER $ 19 -1% 1% 0% 

* Table 83 shows only the proposed payment policy impact on PFS services. We note that these impacts do not 

include the effects of the negative January 2013 conversion factor change under current law.

Table 84 shows the estimated impact of selected policy proposals on total allowed 

charges, by specialty. The following is an explanation of the information represented in 

Table 84: 

● Column A (Specialty): The Medicare specialty code as reflected in our 
CMS-1590-P 682 

physician/supplier enrollment files. 

● Column B (Allowed Charges): The aggregate estimated PFS allowed charges for the 

specialty based on CY 2011 utilization and CY 2012 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 Baseline (PPIS transition, Updated Claims Data, and All Other 

Factors)): This column shows the estimated CY 2013 impact on total allowed charges of the 

changes in the RVUs due to the final year of the PPIS transition, proposed multiple procedure 

payment reduction for the TC of cardiovascular and ophthalmology diagnostic tests furnished on 

the same day (section II.B.4. of this proposed rule), all other proposals that result in minimal 

redistribution of payments under the PFS, the use of CY 2011 claims data to model payment 

rates, and other factors. 

● Column D (Updated Equipment Interest Rate Assumption): This column shows the 

estimated CY 2013 impact on total allowed charges of the changes in the RVUs resulting from 

our proposed update to the equipment interest rate assumption as discussed in section II.A.2.f. of 

this proposed rule. 

● Column E (Primary Care and Care Coordination: Post - Discharge Transitional Care 

Management Services): This column shows the estimated CY 2013 combined impact on total 

allowed charges of the changes in the RVUs resulting from our proposed policy to pay for postdischarge transitional care management services in the 30 days following an inpatient hospital, 

outpatient observation or partial hospitalization, skilled nursing facility (SNF), or community 

mental health center (CMHC) discharge as discussed in section II.H.1. of this proposed rule. We 
CMS-1590-P 683 

would expect a negative impact on all non-primary care specialties due to the application of a 

BN adjustment to reflect the discharge transitional care management policy. 

● Column F (Input Changes for Certain Radiation Therapy Procedures): This column 

shows the estimated CY 2013 combined impact on total allowed charges of the changes in the 

RVUs resulting from our proposal to revise the procedure times for certain radiation therapy 

procedures discussed in section II.B.3.b. of this proposed rule. 

● Column G (Cumulative Impact): This column shows the estimated CY 2013 combined 

impact on total allowed charges of all the proposed changes in the previous columns. 

TABLE 84: CY 2013 PFS Proposed Rule Estimated Impact on Total Allowed Charges by 

Specialty by Selected Proposal* 

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

 Specialty 

 Allowed 

Charges 

(mil) 

Baseline 

(PPIS 

transition, 

new 

utilization 

and other 

factors) 

Updated 

Equipment 

Interest 

Rate 

Assumption 

Discharge 

Transition 

Care 

Management 

 Input 

Changes 

for Certain 

Radiation 

Therapy 

Procedures 

Total 

(Cumulative 

Impact) 

TOTAL $ 85,485 0% 0% 0% 0% 0% 

01-ALLERGY/ IMMUNOLOGY $ 198 0% 1% -2% 1% 0% 

02-ANESTHESIOLOGY $ 1,969 -2% 0% -1% 0% -3% 

03-CARDIAC SURGERY $ 366 -1% 0% -1% 0% -2% 

04-CARDIOLOGY $ 6,565 -1% 0% -1% 0% -3% 

05-COLON AND RECTAL 

SURGERY 

 $ 153 1% 0% -1% 0% 1% 

06-CRITICAL CARE $ 261 1% 0% -1% 0% 0% 

07-DERMATOLOGY $ 3,008 0% 1% -2% 0% -1% 

08-EMERGENCY MEDICINE $ 2,819 0% 0% -1% 0% -1% 

09-ENDOCRINOLOGY $ 434 1% 0% -1% 0% 0% 

10-FAMILY PRACTICE $ 5,872 2% 0% 5% 0% 7% 

11-GASTROENTEROLOGY $ 1,885 1% 0% -1% 0% 0% 

12-GENERAL PRACTICE $ 577 1% 0% -1% 0% 0% 

13-GENERAL SURGERY $ 2,261 1% 0% -1% 0% 0% 

14-GERIATRICS $ 217 2% 0% 2% 0% 4% 

15-HAND SURGERY $ 134 1% 0% -1% 0% 0% 

16-HEMATOLOGY/ ONCOLOGY $ 1,891 0% 1% -2% 0% -1% 

17-INFECTIOUS DISEASE $ 623 2% 0% -1% 0% 1% 

18-INTERNAL MEDICINE $ 11,049 1% 0% 3% 0% 5% 

19-INTERVENTIONAL PAIN 

MGMT 

 $ 533 0% 0% -1% 0% -1% 
CMS-1590-P 684 

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

 Specialty 

 Allowed 

Charges 

(mil) 

Baseline 

(PPIS 

transition, 

new 

utilization 

and other 

factors) 

Updated 

Equipment 

Interest 

Rate 

Assumption 

Discharge 

Transition 

Care 

Management 

 Input 

Changes 

for Certain 

Radiation 

Therapy 

Procedures 

Total 

(Cumulative 

Impact) 

20-INTERVENTIONAL 

RADIOLOGY 

 $ 202 -2% 0% -1% 0% -3% 

21-MULTISPECIALTY 

CLINIC/OTHER PHY 

 $ 201 -1% 0% -1% 0% -2% 

22-NEPHROLOGY $ 2,064 0% 0% -1% 0% -1% 

23-NEUROLOGY $ 1,596 2% 0% -1% 0% 1% 

24-NEUROSURGERY $ 680 0% 0% -1% 0% -1% 

25-NUCLEAR MEDICINE $ 48 -2% -1% -1% 0% -4% 

27-OBSTETRICS/ 

GYNECOLOGY 

 $ 698 1% 0% -1% 0% 0% 

28-OPHTHALMOLOGY $ 5,621 2% 0% -1% 0% 1% 

29-ORTHOPEDIC SURGERY $ 3,609 0% 0% -1% 0% -1% 

30-OTOLARNGOLOGY $ 1,069 1% 1% -1% 0% 0% 

31-PATHOLOGY $ 1,185 -1% 0% -1% 0% -2% 

32-PEDIATRICS $ 64 1% 0% 3% 0% 5% 

33-PHYSICAL MEDICINE $ 980 2% 0% -1% 0% 1% 

34-PLASTIC SURGERY $ 351 1% 0% -1% 0% 0% 

35-PSYCHIATRY $ 1,149 1% 0% -1% 0% 0% 

36-PULMONARY DISEASE $ 1,691 1% 0% -1% 0% 0% 

37-RADIATION ONCOLOGY $ 1,982 -3% -3% -2% -7% -15% 

38-RADIOLOGY $ 4,724 -2% -1% -1% 0% -4% 

39-RHEUMATOLOGY $ 544 0% 1% -2% 0% 0% 

40-THORACIC SURGERY $ 340 -1% 0% -1% 0% -2% 

41-UROLOGY $ 1,905 -1% 0% -1% 0% -2% 

42-VASCULAR SURGERY $ 881 -2% 0% -1% 0% -3% 

43-AUDIOLOGIST $ 57 -3% 0% -1% 0% -5% 

44-CHIROPRACTOR $ 738 2% 0% -1% 0% 0% 

45-CLINICAL PSYCHOLOGIST $ 567 -2% 0% -1% 0% -3% 

46-CLINICAL SOCIAL WORKER $ 400 -2% 0% -1% 0% -3% 

47-DIAGNOSTIC TESTING 

FACILITY 

 $ 848 -5% -2% -2% 1% -8% 

48-INDEPENDENT 

LABORATORY 

 $ 1,064 -2% 1% -2% 1% -2% 

49-NURSE ANES / ANES ASST $ 1,142 -3% 0% -1% 0% -4% 

50-NURSE PRACTITIONER $ 1,606 2% 0% 3% 0% 5% 

51-OPTOMETRY $ 1,048 2% 0% -1% 0% 1% 

52-ORAL/MAXILLOFACIAL 

SURGERY 

 $ 44 1% 1% -1% 0% 0% 

53-PHYSICAL/OCCUPATIONAL 

THERAPY 

 $ 2,263 3% 0% -1% 0% 3% 

54-PHYSICIAN ASSISTANT $ 1,219 1% 0% 2% 0% 3% 

55-PODIATRY $ 1,897 2% 1% -2% 0% 1% 

56-PORTABLE X-RAY $ 104 2% 1% -2% 1% 2% 
CMS-1590-P 685 

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

 Specialty 

 Allowed 

Charges 

(mil) 

Baseline 

(PPIS 

transition, 

new 

utilization 

and other 

factors) 

Updated 

Equipment 

Interest 

Rate 

Assumption 

Discharge 

Transition 

Care 

Management 

 Input 

Changes 

for Certain 

Radiation 

Therapy 

Procedures 

Total 

(Cumulative 

Impact) 

SUPPLIER 

57-RADIATION THERAPY 

CENTERS 

 $ 71 -4% -5% -2% -8% -19% 

98-OTHER $ 19 1% 0% -1% 0% 0% 

*Table 84 shows only the proposed payment policy impact on PFS services. We note that these impacts do not 

include the effects of the negative January 2013 conversion factor change under current law

2. CY 2012 PFS Impact Discussion 

a. Changes in RVUs 

The most widespread specialty impacts of the RVU changes are generally related to 

several factors. First, as discussed in section II.A.2. of this proposed rule, we are currently 

implementing the final year of the 4-year transition to new PE RVUs using the PPIS data that 

were adopted in the CY 2010 PFS final rule with comment period. The impacts of the final year 

of the transition are generally consistent with the impacts that would be expected based on the 

impacts displayed in the CY 2012 final rule with comment period. The second factor is the postdischarge transitional care management proposal, under which we would pay separately for care 

coordination in the 30 days following an inpatient hospital, outpatient hospital observation 

services or partial hospitalization, SNF, or CMHC discharge from the treating physician in the 

hospital to the beneficiary’s primary physician in the community. 

Table 83 also reflects updates to the proposed interest rate assumption used in the 

medical equipment calculation in the PE RVU methodology, the proposed multiple procedure 

payment reduction policy for the technical component of diagnostic cardiovascular and 

ophthalmological procedures, and proposed changes to the inputs for certain radiation therapy 

procedures. 

Table 84 shows the same information as provided in Table 83, but rather than isolating 
CMS-1590-P 686 

the policy impact on physician work, PE, and malpractice separately, Table 84 shows the impact 

of varied proposed policies on total RVUs. 

b. Combined Impact 

 Column E of Table 83 and column G of Table 84 display the estimated CY 2013 

combined impact on total allowed charges by specialty of all the proposed RVU and MPPR 

changes. These impacts range from an increase of 7 percent for family practice to a decrease of 

19 percent for radiation therapy centers. Again, these impacts are estimated prior to the 

application of the negative CY 2013 Conversion Factor (CF) update applicable under the current 

statute. 

Table 85 (Impact of Proposed Rule on CY 2013 Payment for Selected Procedures (Based 

on the March 2012 Preliminary Physician Update)) shows the estimated impact on total 

payments for selected high volume procedures of all of the changes discussed previously. We 

have included CY 2013 payment rates with and without the effect of the CY 2013 negative PFS 

CF update for comparison purposes. We selected these procedures because they are the most 

commonly furnished by a broad spectrum of physician specialties. There are separate columns 

that show the change in the facility rates and the nonfacility rates. For an explanation of facility 

and nonfacility PE, we refer readers to Addendum A of this proposed rule. 
CMS-1590-P 687 

TABLE 85: Impact of Proposed Rule on CY 2013 Payment for Selected Procedures (Based on the Marc

Physician Update)* 

Facility Non

CPT/ HCPCS 1 MOD Short Descriptor CY 20122 CY 20133

(pre 

update) 

% 

Change 

(pre 

update)

CY 2013 

4 (post 

update) 

% 

Change 

(post 

update)

CY 

2012 2

CY 

20133

(pre 

update) 

Cup

11721 Debride nail 6 or more $25.19 $24.37 -3% $17.79 -29% $43.57 $44.00 17000 Destruct premalg lesion $56.16 $56.19 0% $41.01 -27% $81.01 $81.23 27130 Total hip arthroplasty $1,445.58 $1,433.42 -1% $1,046.26 -28% NA NA 27244 Treat thigh fracture $1,231.48 $1,223.23 -1% $892.84 -27% NA NA 27447 Total knee arthroplasty $1,544.29 $1,530.22 -1% $1,116.91 -28% NA NA 33533 Cabg arterial single $1,950.35 $1,897.80 -3% $1,385.21 -29% NA NA 35301 Rechanneling of artery $1,112.35 $1,085.81 -2% $792.54 -29% NA NA 43239 Upper gi endoscopy 

biopsy 

$174.61 $172.62 -1% $126.00 -28% $351.61 $348.96 

66821 After cataract laser 

surgery 

$307.70 $315.79 3% $230.50 -25% $326.08 $334.07 

66984 Cataract surg w/iol 1 

stage 

$760.74 $775.43 2% $565.99 -26% NA NA 

67210 Treatment of retinal 

lesion 

$504.10 $507.37 1% $370.33 -27% $523.84 $524.63 

71010 Chest x-ray NA NA NA NA NA $23.83 $23.02 71010 26 Chest x-ray $8.85 $8.80 -1% $6.42 -27% $8.85 $8.80 77056 Mammogram both 

breasts 

NA NA NA NA NA $112.32 $110.68 

77056 26 Mammogram both 

breasts 

$42.55 $41.63 -2% $30.39 -29% $42.55 $41.63 

77057 Mammogram screening NA NA NA NA NA $81.35 $78.86 
CMS-1590-P 688 

Facility Non

CPT/ HCPCS 1 MOD Short Descriptor CY 20122 CY 20133

(pre 

update) 

% 

Change 

(pre 

update)

CY 2013 

4 (post 

update) 

% 

Change 

(post 

update)

CY 

2012 2

CY 

20133

(pre 

update) 

Cup

77057 26 Mammogram screening $34.38 $33.51 -3% $24.46 -29% $34.38 $33.51 77427 Radiation tx 

management x5 

$177.00 $182.77 3% $133.41 -25% $177.00 $182.77 

88305 26 Tissue exam by 

pathologist 

$36.08 $35.20 -2% $25.69 -29% $36.08 $35.20 

90801 Psy dx interview $119.81 $116.10 -3% $84.74 -29% $152.49 $150.62 90862 Medication 

management 

$44.25 $43.66 -1% $31.87 -28% $58.54 $58.89 

90935 Hemodialysis one 

evaluation 

$72.84 $70.74 -3% $51.63 -29% NA NA 

92012 Eye exam established 

pat 

$51.40 $52.46 2% $38.29 -25% $82.71 $84.62 

92014 Eye exam & treatment $78.29 $79.20 1% $57.81 -26% $119.81 $122.53 92980 Insert intracoronary 

stent 

$837.67 $804.20 -4% $586.99 -30% NA NA 

93000 Electrocardiogram 

complete 

NA NA NA NA NA $19.06 $17.94 

93010 Electrocardiogram 

report 

$8.51 $8.12 -5% $5.93 -30% $8.51 $8.12 

93015 Cardiovascular stress 

test 

NA NA NA NA NA $88.50 $83.94 

93307 26 Tte w/o doppler 

complete 

$45.95 $44.34 -4% $32.36 -30% $45.95 $44.34 

93458 26 L hrt artery/ventricle 

angio 

$315.87 $315.12 0% $230.00 -27% $315.87 $315.12 

98941 Chiropractic 

manipulation 

$30.63 $30.46 -1% $22.23 -27% $36.08 $36.22 

99203 Office/outpatient visit $74.88 $74.46 -1% $54.35 -27% $105.18 $106.28 
CMS-1590-P 689 

Facility Non

CPT/ HCPCS 1 MOD Short Descriptor CY 20122 CY 20133

(pre 

update) 

% 

Change 

(pre 

update)

CY 2013 

4 (post 

update) 

% 

Change 

(post 

update)

CY 

2012 2

CY 

20133

(pre 

update) 

Cup

new 

99213 Office/outpatient visit 

est 

$49.69 $49.76 0% $36.32 -27% $70.46 $71.76 

99214 Office/outpatient visit 

est 

$76.24 $76.49 0% $55.83 -27% $104.16 $105.26 

99222 Initial hospital care $133.09 $133.70 0% $97.58 -27% NA NA 99223 Initial hospital care $195.38 $196.99 1% $143.78 -26% NA NA 99231 Subsequent hospital 

care 

$38.12 $37.91 -1% $27.67 -27% NA NA 

99232 Subsequent hospital 

care 

$69.78 $70.06 0% $51.14 -27% NA NA 

99233 Subsequent hospital 

care 

$100.07 $100.53 0% $73.37 -27% NA NA 

99236 Observ/hosp same date $212.05 $211.88 0% $154.65 -27% NA NA 99239 Hospital discharge day $103.13 $103.91 1% $75.84 -26% NA NA 99283 Emergency dept visit $60.25 $59.57 -1% $43.48 -28% NA NA 99284 Emergency dept visit $114.71 $113.73 -1% $83.01 -28% NA NA 99291 Critical care first hour $217.16 $216.62 0% $158.11 -27% $267.20 $268.75 99292 Critical care addl 30 

min 

$108.92 $108.65 0% $79.30 -27% $119.47 $119.82 

99348 Home visit est patient NA NA NA NA NA $82.03 $81.57 99350 Home visit est patient NA NA NA NA NA $171.21 $172.96 

G0008 Immunization admin NA NA NA NA NA $24.17 $25.05 

*The CY 2013 payment rates are likely to differ from those shown in 85, as the CY 2013 CF is not yet final. 
CMS-1590-P 690 

1 CPT codes and descriptions are copyright 2012American Medical Association. All Rights Reserved. Applicable FARS/DFARS app2 Payments based on the 2012conversion factor of 34.0376 3 Payments based on the 2012 conversion factor of 34.0376, adjusted to 33.8572 to include the BN adjustment. 4 Payments based on the 2013conversion factor of 24.7124, which includes the BN adjustment. 
CMS-1590-P 691 

D. Effect of Proposed Changes to Medicare Telehealth Services Under the PFS

As discussed in section II.E.3 of this proposed rule, we are proposing to add several new 

codes to the list of Medicare telehealth services. While 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 Definition of Certified Registered Nurse Anesthetists’ (CRNA) Services 

As discussed in section II.K.1. of this proposed rule, we propose to define “anesthesia 

and related care” as used in the statutory benefit category for CRNAs under section 1861(bb)(2) 

of the Act to include those services that are related to anesthesia and included within the state 

scope of practice for CRNAs in the state in which the services are furnished. CMS has been 

requested to clarify the definition with regard to chronic pain management services. Contractors 

have reached different conclusions as to whether the statutory definition of “anesthesia services 

and related care” encompasses the chronic pain management services delivered by CRNAs. 

Given variations in state scopes of practice, we expect that differences on whether CRNAs can 

bill Medicare directly for these services will continue to exist. In addition, current Medicare 

policies do not prohibit CRNAs from furnishing these services in states where the scope of 

practice allows them to do so, but only prohibit them from billing Medicare directly. As a result 

of these two factors, we do not expect a significant change in how many services are billed to 

Medicare and therefore, we estimate no significant budgetary impact from this proposed change. 

F. Effects of Proposed Change to Ordering Requirements for Portable X-Ray Services Under the 

PFS

As discussed in section III.K.2. of this proposed rule, we are proposing to revise our 

current regulation that limits ordering of portable x-ray services to only a doctor of medicine or a 
CMS-1590-P 692 

doctor of osteopathy to allow other physicians and nonphysician practitioners (acting within the 

scope of State law and their Medicare benefit) to order portable x-ray services. We estimate no 

significant impact on PFS expenditures from the proposed additions. 

G. Geographic Practice Cost Indices (GPCIs)

As discussed in section II.E. 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 2013, we are not proposing any revisions related to the 

data or methodologies used to calculate the GPCIs. However, since the 1.0 work GPCI floor 

provided in section 1848 (e)(1)(E) of the Act is set to expire prior to the implementation of the 

CY 2013 PFS, the proposed CY 2013 physician work GPCIs and summarized geographic 

adjustment factors (GAFs) published in addendums D and E of this CY 2013 PFS proposed rule 

do not reflect the 1.0 work GPCI floor for CY 2013. As required by section 1848 (e)(1)(G) and 

section1848 (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 applicable in CY 2013. 

H. Other Provisions of the Proposed Regulation

1. Ambulance Fee ScheduleAs discussed in section III.A. of this proposed rule, section 306 of the TPTCCA and 

section 3007 of the MCTRJCA require the extension of certain add-on payments for ground 

ambulance services, and the extension of certain rural area designations for purposes of air 

ambulance payment, through CY 2012. As further discussed in section III.A. of this proposed 

rule, this legislation is self-implementing, and we are proposing to amend the regulation text at 

§414.610 only to conform the regulations to these self-implementing statutory requirements. As 

a result, we are not making any policy proposals associated with these legislative provisions and 

there is no associated regulatory impact. 
CMS-1590-P 693 

2. Part B Drug Payment: ASP Issues 

As discussed in section III of this proposed rule, we are proposing to update the AMPbased price substitution policy that would allow Medicare to pay based off lower market prices 

for those drugs and biologicals that consistently exceed the applicable threshold percentage. Our 

impact analysis is unchanged from last year (76 FR 73462): based on estimates published in 

various OIG reports cited in the CY 2012 PFS final rule with comment period (76 FR 73290-1), 

we believe that this proposal will generate minor savings for the Medicare program and its 

beneficiaries since any substituted prices would be for amounts less than the calculated 106 

percent of the ASP. 

Our policy clarification regarding Pharmacy Billing for Part B Drugs Administered 

Incident to a Physician’s Services which is discussed in section III of this proposed rule states 

that only physicians and not pharmacies (or DME suppliers) are allowed to bill Medicare under 

Part B for drugs administered in physicians’ offices. We do not believe that this clarification 

will significantly impact the quantity or payment amount for part B drugs that are administered 

through implanted DME and or the procedures used to refill such pumps. 

3. Medicare Program; Durable Medical Equipment (DME) Face-to-Face Encounters and Written 

Orders Prior to Delivery 

a. Overall Impact 

 We estimate the overall economic impact of this provision on the health care sector to be 

a cost of $49.95 million in the first year and $285.2 million over 5 years. This overall impact is 

comprised of additional administrative paperwork costs to private sector providers; a slight 

increase in Medicare spending, consisting of additional costs and some offsetting savings; and 

additional opportunity and out-of-pocket costs to Medicare beneficiaries. We believe there are 

likely to be other benefits and cost savings result from the DME face-to-face requirement, 
CMS-1590-P 694 

however, many of those benefits cannot be quantified. For instance, we expect to see savings in 

the form of reduced fraud, waste, and abuse, including a reduction in improper Medicare fee-forservice payments (note that not all improper payments are fraudulent). Our detailed cost and 

benefit analysis is explained below. We are specifically soliciting comment on the potential 

increased costs and benefits associated with this provision. 

TABLE 86: Overall Economic Impact to Health Sector (in millions) 

Year 1 5 Years 

Private Sector (Paperwork 

Cost) $11.2 $94.2 

Net Medicare impact of 

additional visits and G code 

billings 

$5 $30 

Beneficiaries $29. 75 $161

Total Economic Impact to 

Health Sector $ 49.95 $ 285.2 

The definition of small entity in the RFA includes non-profit organizations. Most 

suppliers and providers are small entities as that term is used in the RFA. Likewise, the vast 

majority of physician and NP practices are considered small businesses according to the Small 

Business Administration's size standards with total revenues of $10 million or less in any 1 year. 

While the economic costs and benefits of this rule are substantial in the aggregate, the economic 

impacts on individual entities will be relatively small. We estimate that 90 to 95 percent of DME 

suppliers and practitioners who order DME are small entities under the RFA definition. 

Physicians and other professionals would receive extra payments for some of the costs imposed, 

and other costs (for example, for additional practitioner visits) would be reimbursed by Medicare 

under regular payment rules. The rationale behind requiring a face-to-face encounter is to reduce 

inappropriate claims from those DME suppliers who have been abusing or defrauding the 

program. The impact on these suppliers could be significant, however since the purpose of the 

statute and this regulation is to reduce abusive and fraudulent DME sales, we do not view the 

burden placed on those providers in the form of lost revenues as a condition that we must 
CMS-1590-P 695 

mitigate. We believe that the effect on legitimate suppliers and practitioners would be minimal. 

Anticipated Effects 

b. Costs 

(1) Private Sector Paperwork Costs 

We believe that most practitioners are already seeing the beneficiary no more than 90 

days prior to the written order or within 30 days after the order is written in certain 

circumstances. However this regulation potentially requires increased documentation. 

Although we have no quantitative data for a specific dollar figure for the additional DME 

that may now be authorized in accordance with §410.38(g), nor can we determine if there would 

be cost avoidance and a reduction of unnecessary DME, we acknowledge the potential for this 

provision to surpass the economically significant threshold. We do not believe that this proposed 

rule would significantly affect the number of legitimate written orders for DME. However, we 

would expect a decline in fraudulent, wasteful and abusive orders, thereby causing a decrease in 

the amount paid for DME overall. 

The covered items of DME as outlined in the M Pages, including the proposed list of 

Specified Covered Items, contains items that meet at least one of the criteria. The four criteria 

are as follows: (1) items that currently require a written order prior to delivery per instructions in 

our Program Integrity Manual; (2) items that cost more than $1,000; (3) items that we, based on 

our experience and recommendations from the DME MACs, believe are particularly susceptible 

to fraud, waste, and abuse; (4) items determined by CMS as vulnerable to fraud, waste and abuse 

based on reports of the HHS Office of Inspector General, the Government Accountability Office 

or other oversight entities. We are requesting comments on our criteria. 

We also have estimated the number of different covered Medicare itemssubject to this 

proposed rule at approximately 164 HCPCS codes for items of DME. As new products enter the 
CMS-1590-P 696 

market this number could increase, which could increase the impact. In addition, we propose a 

G-code to pay physicians' for documenting the encounter conducted by a PA, a NP, or a CNS. 

We anticipate there would be an impact as a result of additional office visits for the faceto-face encounter and the additional time spent by physicians to document the face-to-face 

encounters with a beneficiary when it is furnished by a PA, a NP, or a CNS. 

In our estimate of overall cost we include the estimates from section III, of this proposed 

rule (Collection of Information Requirements section). These are estimated at $11.2 million in 

year 1 and $ 94.2 million over 5 years. These are driven by the physician documenting face-toface encounters with a beneficiary when it is furnished by a PA, a NP, or a CNS, including the 

time to communicate the practitioners findings to physicians so they can complete the necessary 

documentation. 

TABLE 87: Private Sector Paperwork Costs 

Year 1 

(in millions) 

5 Years 

(in millions) 

Physician time to document occurrence of a face-to-face 

encounter cost 

$9.8 $82.6 

PA, NP, or CNS costs $1.4 $11.6 

Total Cost $11.2 $94.2 

(2) Medicare Costs 

Medicare would incur additional costs associated with this proposed rule related to 

additional face-to-face encounters in the form of office visits, and additional payment for time 

spent documenting the face-to-face encounter if furnished by the PA, NP or CNS and not by the 

physician directly. Subsequently, a G-Code is being created to allow Medicare payment to 

physicians for documenting the face-to-face encounters that are furnished by a PA, NP, and 

CNS, and is included in this proposed rule. 

From a programmatic standpoint we believe that there would be 750,000 additional office 

visits billed and 500,000 G code claims for the documentation. It is difficult to determine how 
CMS-1590-P 697 

many PAs, NPs or CNSs wrote orders for covered items of DME, and while we lack exact 

empirical data, in order to provide an estimate, we assumed that 5 percent of the orders for 

covered items of DME were written by a PA, NP or CNS. For the purpose of this estimate we 

assume that each order requires a separate face-to-face encounter, recognizing fully that the 

estimate might be inflated. 

While we believe that currently the majority of practitioners evaluate beneficiaries before 

ordering DME, some may not, and therefore, a certain number of beneficiaries would be required 

to have a new visit in order to fulfill the face-to-face encounter requirement. Actuarial estimates 

indicate approximately 5 percent of those obtaining covered items of DME in a given year did 

not see a practitioner in the 90 days preceding the order or in the 30 days after the order was 

written. We estimate that 500,000 beneficiaries would not see their practitioners in the 90 days 

prior to the written order for the covered item or in the 30 days after the order is written. We 

assume that 1.5 visits per year per affected beneficiary would be required to cover the DME 

services that currently fail to meet the face- to- face requirement. The range would be about one 

to three; possibly less than one if many beneficiaries choose not to meet the requirement or 

reschedule services. DME claims for beneficiaries who failed to meet the physician contact 

requirements averaged 3 line items per beneficiary. However, about 40 percent of these line 

items occur on the same date and so probably refer to the same event and could be authorized 

during a single visit. Some additional coordination is probable for DME purchases within a 

narrow time frame. To estimate the impact of the additional office visits we assumed 750,000 

additional office visits (1.5 visits * 500,000 beneficiaries). We also assumed that the average 

cost for these office visits is around $65, which is consistent with a mid-level office visit under 

the PFS. This represents the total amount that the practitioners would receive, either from 

Medicare or the beneficiary, who is responsible for the 20 percent coinsurance. 
CMS-1590-P 698 

Physicians are now required to document the face-to-face encounter if it was furnished by 

a PA, NP, or CNS. In order to allow payment for this documentation, a G code is established for 

this service. There are approximately 10 million DME users and it was assumed that roughly 5 

percent of face-to-face encounters are actually furnished by these other practitioner types, 

thereby requiring documentation of the encounter. Therefore, it was assumed that about 500,000 

of these documentation services would be billed. We cannot predict with any certainty the cost 

of this new service, but believe that $15 is a reasonable estimate. This represents the total 

amount that the physician would receive, either from Medicare or the beneficiary, who is 

responsible for the 20 percent coinsurance. 

Therefore the estimated gross cost is estimated to be $45 million in year 1 and $250 

million over 5 years; note that there are also savings to Medicare that must be netted against the 

cost of additional practitioner office visits, which are described later in the Benefits section. 

There is a high degree of uncertainty surrounding this estimate because it is difficult to predict 

how physicians and beneficiaries would respond to the new requirement. 

This provision would assist in providing better documentation which may help to lower 

the error rate and thus reduce improper payments, including those stemming from waste, fraud 

and abuse. Since there is a large amount of potential variation in the amount of time that a faceto-face encounter may take for an item of DME, as a proxy our estimate is based on the amount 

of time needed for a mid-level visit to evaluate a beneficiary (E&M code 99213). The time 

allotted for this visit to furnish the face-to-face evaluation under a 99213 is 15 minutes. We 

welcome comments as to the appropriateness of E&M Code 99213 as a proxy measure of time 

required for a face-to-face encounter. 

Based on actual data, projecting these historical patterns in light of the draft regulation is 

not straight-forward. Some line items may be bundled (perhaps because they are used together). 
CMS-1590-P 699 

Beneficiaries may also change their behavior in response to the regulation. For example, 

beneficiaries would be required to visit a physician in order for Medicare to pay for a new piece 

of equipment may substitute this visit for a later visit that would have been for a routine service. 

In this situation, the overall number of visits would not increase. Moreover, some beneficiaries 

may choose not to pursue the DME item at that time. On the other hand, the proposed rule 

points out that some of the encounters reported on the practitioner claim now may not qualify to 

support the need for the item of DME. We assume that beneficiaries would decide not to 

schedule 10 percent of the additional visits required as a result of not needing the DME item and 

that some would substitute a required service for a later planned visit. 

TABLE 88: Medicare 5-Year Costs for Additional Face-to-Face Visits and G Code Billings 

2013 2014 2015 2016 2017 

$45 $45 $50 $50 $60 

*These costs represent 80 percent of the allowed charges for the additional visits and the new G codes. 

The requirement for a face-to-face encounter with a beneficiary in a certain time period 

as a condition of payment for DME is a new statutory requirement. It is not subject to the 

physician fee schedule budget neutrality requirement under section 1848(c)(2)(B)(ii)(II) of the 

Act. However, by regulation, we are proposing to make an additional payment through a new 

G-code for physician work documenting the face-to-face encounters that are performed by a PA, 

NP, and CNS. This additional regulatory spending is subject to the physician fee schedule 

budget neutrality requirement under section 1848(c)(2)(B)(ii)(II) of the Act. 

 (c) Beneficiary Cost Impact 

From a programmatic standpoint, approximately 5 percent of those obtaining covered 

items of DME in that year did not see a practitioner in the 90 days preceding the order or in the 

30 days after the order was written. We estimate that 500,000 beneficiaries would not see their 

practitioners in the 90 days prior to the written order for the covered item or in the 30 days after 
CMS-1590-P 700 

the order is written. As mentioned above, we assume that 1.5 visits per year per affected 

beneficiary would be required to cover the DME services that currently fail to meet the face to 

face requirement. The range would be about one to three; possibly less than one if many 

beneficiaries choose not to meet the requirement or reschedule services. DME claims for 

beneficiaries who failed to meet the physician contact requirements averaged 3 line items per 

beneficiary. However, about 40 percent of these line items occur on the same date and so 

probably refer to the same event and could be authorized during a single visit. Some additional 

coordination is probable for DME purchases within a narrow time frame. There are effects on 

travel time and cost for these beneficiaries. If it takes a beneficiary 1.25 hours to go to a 

practitioner, the total estimate is approximately 937,500 hours of time for this proposed rule. We 

assume that an average trip requires one hour and 15 minutes (45 minutes of round trip travel 

time and 30 minutes in the doctor's office—half for waiting and half for time with the staff). As a 

proxy we use $20 to estimate the cost per hour including loss of leisure time and travel cost for a 

beneficiary to see a practitioner. This is consistent with previous estimates of beneficiary leisure 

time as proposed in the May 4, 2011 proposed rule entitled "Medicare & Medicaid Programs; 

Influenza Vaccination Standard for Certain Medicare & Medicaid Participating Providers and 

Suppliers" 76 FR 25469. This creates an economic cost of nearly $18.75 million in year 1. Over 

5 years this cost could reach $105 million. There will be additional out of pocket expenses at the 

20 percent Medicare Part B coinsurance. We estimated this cost to be $10 million in year 1 and 

$56 million over 5 years. 

TABLE 89: Beneficiary Cost Impact Resulting from Additional Face-to-Face Visits 

to Obtain DME Services 

Year 1 5 Years 

Total beneficiaries visits impacted 750,000 4.2 million 

Time per beneficiary 1.25 hours 1.25 hours 

Total Time 937,500 5.25 million 

Beneficiary Time Cost ($20) $18. 75 

million 

$105 million 
CMS-1590-P 701 

Year 1 5 Years 

Out of Pocket Expense $10 million $56 million 

Estimated Total Beneficiary Cost 

Impact 

$29. 75 

million 

$161 million 

* These costs represent 20 percent of the allowed charges for the additional visits and the new G codes. 

b. Benefits

There would be quantifiable benefits from an expected reduction in Medicare DME 

services provided. In addition, we anticipate additional, qualitative benefits from a decrease in 

waste, fraud, and abuse, which would decrease the number of services. Further, requiring that 

there be a face-to-face evaluation of the beneficiary helps ensure appropriate orders based on the 

individual’s medical condition, which increases the quality of care that the beneficiary receives. 

It is difficult to measure how much waste, fraud, and abuse will be prevented as a result of this 

proposed rule since it is impossible to determine what would have happened in the absence of the 

proposed rule. This provision is expected to improve physician’s documentation of DME, and 

therefore, will help reduce improper payments and move the agency towards its strategic goal to 

reduce the Medicare fee-for-service error rate for DME items which has a higher error rate than 

other Medicare services. The Comprehensive Error Rate Testing (CERT) program error rate for 

DME is high. Fraud is an improper payment, but not all improper payments are fraud. 

Therefore, creating a measure of how much this proposed rule would save in terms of a 

reduction in waste, fraud and abuse is not possible. With that stated, in 2009 Medicare paid $1.7 

billion for DME items covered by this proposed rule, and we estimate that $1.9 billion will be 

paid for covered items in 2012, and $9.9 billion over 5 years. Preventing waste, fraud and abuse 

by changing behavior that results in just a small percentage reduction in inappropriate or 

unnecessary ordering of DME services will generate Medicare savings. This is an area where 

savings can be found through increased oversight, such as this regulation proposes. We believe 

that the cost of the visits will be offset by the savings produced by this provision. 
CMS-1590-P 702 

We project Medicare savings from reduced DME services; these savings partially offset 

the costs of additional physician office visits and documentation payments described earlier in 

the impact analysis. The year-to-year Medicare savings from reduced DME services is as 

follows: 

TABLE 90: Year-to-Year Medicare Savings from Reduced DME Services 

 2013 2014 2015 2016 2017 

DME 

savings -$40 -$40 -$45 -$45 -$50 

Based on an analysis of 2007 DME claims, approximately 2 percent of total DME 

spending was for those beneficiaries who had little contact with their physician during the year. 

For this subset of spending we assumed that there would be a 20 percent reduction in spending 

due to the face-to- face requirement. We found similar reductions in DME expenditures among 

managed care enrollees compared to fee for service (FFS) beneficiaries in the Medical 

Expenditure Panel Survey. This assumption is fairly speculative but we think it is modest 

compared to the estimates of fraud and abuse reported elsewhere. The savings occurs because 

some beneficiaries will not choose to go to the physician to authorize the DME item, some 

physicians will not order the items that would otherwise have been provided in the absence of the 

regulation, and some suppliers will not be able to achieve a payment that might have occurred 

through an unnecessary sale or outright fraud. 

The overall net impact to Medicare of the DME face-to-face encounter policy is $5 

million in the first year and $30 million over the first 5 years. 

This regulation produces an extra benefit that is difficult to quantify, but is an extremely 

positive one in terms of greater practitioner involvement. By increasing practitioner interactions 

with beneficiaries before ordering DME, beneficiaries would receive more appropriate DME and 

benefiting from higher quality care. Beneficiaries would also benefit from reduced out-of-
CMS-1590-P 703 

pockets costs by not having to pay for unnecessary DME. This accomplishes the objective of 

achieving greater practitioner accountability noted in the provisions of and the amendments 

made by section 6407 and other sections of the Affordable Care Act. We welcome public 

comment on the benefits of the DME face-to-face requirement, including any data that could 

help quantify the expected reduction in fraud, improper payments, or improved beneficiary 

quality of care. 

Alternatives Considered 

In this proposed rule, we consider a variety of options and have sought comments on 

these options in other sections of this proposed rule. We expect public comment on the way in 

which the supplier should be notified that a face-to-face has occurred wanting to limit the 

potential burden. We proposed several options for the physician documentation of a face-to-face 

encounter furnished by that physician. We believe just submitting the medical record for the 

applicable date of service would create the least cost while still producing the desired benefits. 

In this proposed rule we have also set forth different options of what physician documentation of 

a face-to-face encounter furnished by a PA, NP or CNS could look like, in the hope of receiving 

comments on determining the method that will create the least potential burden. 

There are also options to change the list of covered DME, either by expanding it to cover 

more items or by minimizing it to cover fewer items with low unit costs. We welcome comment 

on our selection criteria. 

Finally, there are other possible periods of time that could be set as the window within 

which face-to-face encounters must occur. We believe that the consistency with the home health 

rule benefits providers of services and suppliers, and beneficiaries but welcome comment on this 

proposal. 

4. Non-Random Prepayment Review 
CMS-1590-P 704 

We estimate no significant budgetary impact. We believe that the overall costs for most 

providers and suppliers would remain the same unless they are subject to non-random 

prepayment complex medical review for an extended period of time. 

5. Ambulance Coverage-Physician Certification Statement 

 We estimate no significant budgetary impact. 

6. Physician Compare Website 

Section IV.N.2. of this proposed rule discusses the background of the Physician Compare 

Website. As described in section IV.N.2. of this proposed rule, we propose to develop aspects of 

the Physician Compare Website in stages. In the first stage, which was completed in 2011, we 

posted the names of those eligible professionals who satisfactorily participated in the 2009 

Physician Quality Reporting System. The second phase of the plan, which was completed in 

2012, included posting the names of eligible professionals who were successful electronic 

prescribers under the 2009 eRx Incentive Program, as well as eligible professionals (EPs) who 

participate in the EHR Incentive Program. The next phase of the plan includes posting of 

performance information with respect to the 2012 Physician Quality Reporting System GPRO 

measures which will be completed no sooner than 2013. 

We are proposing to include performance information for the 2013 Physician Quality 

Reporting System GPRO web interface measures data no sooner than 2014, in addition to 2013 

patient experience data for group practices participating in the 2013 Physician Quality Reporting 

System GPRO. As reporting of physician performance rates and patient experience data on the 

Physician Compare Website will be performed directly by us using the data that we collect under 

the 2012 Physician Quality Reporting System GPRO and other data collection methods, we do 

not anticipate any notable impact on eligible professionals with respect to the posting of 

information on the Physician Compare Website. 
CMS-1590-P 705 

7. Physician Payment, Efficiency, and Quality Improvements – Physician Quality Reporting 

System 

According to the 2010 Reporting Experience Report, a total of $391,635,495 in Physician 

Quality Reporting System incentives was paid by CMS for the 2010 program year, which 

encompassed 168,843 individual eligible professionals. In 2010, eligible professionals earned a 

2.0 percent incentive (i.e., a bonus payment equal to 2.0 percent of the total allowed part B 

charges for covered professional services under the PFS furnished by the eligible professional 

during the reporting period) for satisfactory reporting under the Physician Quality Reporting 

System. For 2013 and 2014, eligible professionals can earn a 0.5 percent incentive for 

satisfactory reporting, a reduction of 1.5 percent from 2010. Therefore, based on 2010,which is 

the latest year in which PQRS has full participation data, we would expect that approximately 

$97 million (approximately 1⁄4 of $391,635,495) in incentive payments would be distributed to 

eligible professionals who satisfactorily report. However, we expect that, due to the 

implementation of payment adjustments beginning in 2015, participation in the Physician 

Quality Reporting System would rise incrementally to approximately 300,000 eligible 

professionals and 400,000 eligible professionals in 2013 and 2014, respectively. 

 The average incentive distributed to each eligible professional in 2010 was $2,157. 

Taking into account the 1.5 percent incentive reduction from 2.0 percent in 2010 to 0.5 percent 

in 2013 and 2014, we estimate that the average amount per eligible professional earning an 

incentive in 2013 and 2014 would be $539. Therefore, we estimate that the Physician Quality 

Reporting System would distribute approximately $162 million ($539 x 300,000 eligible 

professionals) and $216 million ($539 x 400,000 eligible professionals) in incentive payments in 

2013 and 2014, respectively. We believe these incentive payments will help offset the cost to 

eligible professionals for participating in the Physician Quality Reporting System for the 
CMS-1590-P 706 

applicable year. Please note that, beginning 2015, incentive payments for satisfactory reporting 

in the Physician Quality Reporting System will cease and payment adjustments for not 

satisfactory reporting will commence. 

 We note that the total burden associated with participating in the Physician Quality 

Reporting System is the time and effort associated with indicating intent to participate in the 

Physician Quality Reporting System, if applicable, and submitting Physician Quality Reporting 

System quality measures data. When establishing these burden estimates, we assume the 

following: 

• The requirements for reporting for the Physician Quality Reporting System 2013 and 

2014 incentives and payment adjustments for 2015 and beyond would be established as 

proposed in this 2013 Medicare PFS proposed rule. 

• For an eligible professional or group practice using the claims, registry, or EHR-based 

reporting mechanisms, we assume that the eligible professional or group practice would 

report on 3 measures. 

• With respect to labor costs, we believe that a billing clerk will handle the administrative 

duties associated with participating, while a computer analyst will handle duties related to 

reporting Physician Quality Reporting System quality measures. According to the 

Bureau of Labor Statistics, the mean hourly wage for a billing clerk is approximately 

$16/hour whereas the mean hourly wage for a computer analyst is approximately 

$40/hour. 

 For an eligible professional who wishes to participate in the Physician Quality Reporting 

System as an individual, the eligible professional need not indicate his/her intent to participate. 

The eligible professional may simply begin reporting quality measures data. Therefore, these 

burden estimates for individual eligible professionals participating in the Physician Quality 
CMS-1590-P 707 

Reporting System are based on the reporting mechanism the individual eligible professional 

chooses. However, we believe a new eligible professional or group practice would spend 5 

hours—which includes 2 hours to review the Physician Quality Reporting System measures list, 

review the various reporting options, and select a reporting option and measures on which to 

report and 3 hours to review the measure specifications and develop a mechanism for 

incorporating reporting of the selected measures into their office work flows. Therefore, we 

believe that the initial administrative costs associated with participating in the Physician Quality 

Reporting System would be approximately $80 ($16/hour x 5 hours). 

 With respect to an eligible professional who participates in the Physician Quality 

Reporting System via claims, the eligible professional 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 Physician Quality Reporting System collects QDCs as 

additional (optional) line items on the existing HIPAA transaction 837-P and/or CMS Form 1500 

(OCN: 0938-0999). Based on our experience with Physician Voluntary Reporting Program 

(PVRP), we continue to estimate that the time needed to perform all the steps necessary to report 

each measure via claims will range from 0.25 minutes to 12 minutes, depending on the 

complexity of the measure. Therefore, the time spent reporting 3 measures would range from 

0.75 minutes to 36 minutes. Using an average labor cost of $40/hour, we estimate that time cost 

of reporting for an eligible professional via claims would range from $0.50 (0.75 minutes x 

$40/hour) to $24.00 (36 minutes x $40/hour) per reported case. With respect to how many cases 

an eligible professional would report when using the claims-based reporting mechanism, we 

proposed that an eligible professional would need to report on 50 percent of the eligible 

professional’s applicable cases. The actual number of cases on which an eligible professional 

would report would vary depending on the number of the eligible professional’s applicable cases. 
CMS-1590-P 708 

However, in prior years, when the reporting threshold was 80 percent, we found that the median 

number of reporting cases for each measure was 9. Since we are proposing to reduce the 

reporting threshold to 50 percent, we estimate that the average number of reporting cases for 

each measure would be reduced to 6. Based on these estimates, we estimate that the total cost of 

reporting for an eligible professional choosing the claims-based reporting mechanism would 

range from ($0.50/per reported case x 6 reported cases) $3.00 to ($24.00/reported case x 6 

reported cases) $144. 

 We note that, for the 2015 and 2016 PQRS payment adjustments, we are proposing an 

administrative claims reporting option for eligible professionals and group practices. The burden 

associated with reporting using the administrative claims reporting option is the time and effort 

associated with using this option. To submit quality measures data for PQRS using the 

administrative claims reporting option, an eligible professional or group practice would need to 

(1) register as an administrative claims reporter for the applicable payment adjustment and (2) 

report quality measures data. With respect to registration, we believe it would take 

approximately 2 hours to register for to participate in PQRS as an administrative claims reporter. 

Therefore, we estimate that the cost of undergoing the GPRO selection process will be ($16/hour 

x 2 hours) $32. With respect to reporting, we note that any burden associated with reporting 

would be negligible, as an eligible professional or group practice would not be required to attach 

reporting G-codes on the claims they submit. Rather, CMS would bear the burden of reporting 

with respect to selecting which measures to report. We note that there would be no additional 

burden on the eligible professional or group practice to submit these claims, as the eligible 

professional or group practice would have already submitted these claims for reimbursement 

purposes. 
CMS-1590-P 709 

 With respect to an eligible professional or group practice who participates in the 

Physician Quality Reporting System via a qualified registry, direct EHR product, or EHR data 

submission vendor product, we believe there would be little to no burden associated for an 

eligible professional to report Physician Quality Reporting System quality measures data to 

CMS, because the selected reporting mechanism submits the quality measures data for the 

eligible professional. While we note that there may be start-up costs associated with purchasing 

a qualified registry, direct EHR product, or EHR data submission vendor, we believe that an 

eligible professional or group practice would not purchase a qualified registry, direct EHR 

product, or EHR data submission vendor product solely for the purpose of reporting Physician 

Quality Reporting System quality measures. Therefore, we have not included the cost of 

purchasing a qualified registry, direct EHR, or EHR data submission vendor product in our 

burden estimates. 

 Unlike eligible professionals who choose to report individually, we note that eligible 

professionals choosing to participate as part of a group practice under the GPRO must indicate 

their intent to participate in the Physician Quality Reporting System as a group practice. The 

total burden for group practices who submit Physician Quality Reporting System quality 

measures data via the proposed GPRO web-interface would be the time and effort associated 

with submitting this data. To submit quality measures data for the Physician Quality Reporting 

System, a group practice would need to (1) be selected to participate in the Physician Quality 

Reporting System GPRO and (2) report quality measures data. With respect to the 

administrative duties for being selected to participate in the Physician Quality Reporting System 

as a GPRO, we believe it would take approximately 6 hours – including 2 hours to decode to 

participate in the Physician Quality Reporting System as a GPRO, 2 hours to self-nominate, and 

2 hours to undergo the vetting process with CMS officials – for a group practice to be selected to 
CMS-1590-P 710 

participate in the Physician Quality Reporting System GPRO for the applicable year. Therefore, 

we estimate that the cost of undergoing the GPRO selection process would be ($16/hour x 6 

hours) $96. With respect to reporting, the total reporting burden is the time and effort associated 

with the group practice submitting the quality measures data (that is, completed the data 

collection interface). Based on burden estimates for the PGP demonstration, which uses the 

same data submission methods, we estimate the burden associated with a group practice 

completing the data collection interface would be approximately 79 hours. Therefore, we 

estimate that the report cost for a group practice to submit Physician Quality Reporting System 

quality measures data for the proposed reporting options in an applicable year would be 

($40/hour x 79 hours) $3,160. 

 Eligible professionals who wish to quality for an additional 0.5% Maintenance of 

Certification Program incentive must “more frequently” than is required to qualify for or 

maintain board certification status participate in a qualified Maintenance of Certification 

Program for 2013 and/or 2014 and successfully complete a qualified Maintenance of 

Certification Program practice assessment for the applicable year. Although we understand that 

there is a cost associated with participating in a Maintenance of Certification Board, we believe 

that most of the eligible professionals attempting to earn this additional incentive would already 

be enrolled in a Maintenance of Certification board for reasons other than earning the additional 

Maintenance of Certification Program incentive. Therefore, the burden to earn this additional 

incentive would depend on what a certification board establishes as “more frequently” and the 

time needed to complete the practice assessment component. We expect that the amount of time 

needed to complete a qualified Maintenance of Certification Program practice assessment would 

be spread out over time since a quality improvement component is often required. With respect 

to the practice assessment component, according to an informal poll conducted by ABMS in 
CMS-1590-P 711 

2012, the time an individual spends to complete the practice assessment component of the 

Maintenance of Certification ranges from 8-12 hours. 

 Aside from the burden of eligible professionals and group practices participating in the 

Physician Quality Reporting System, we believe that registry, direct EHR, and EHR data 

submission vendor products incur costs associated with participating in the Physician Quality 

Reporting System. 

 With respect to qualified registries, the total burden for qualified registries who submit 

Physician Quality Reporting System Quality Measures Data would be the time and effort 

associated with submitting this data. To submit quality measures data for the proposed program 

years for Physician Quality Reporting System, a registry would need to (1) become qualified for 

the applicable year and (2) report quality measures data on behalf of its eligible professionals. 

With respect to administrative duties related to the qualification process, we estimate that it will 

take a total of 10 hours – including 1 hour to complete the self-nomination statement, 2 hours to 

interview with CMS, 2 hours to calculate numerators, denominators, and measure results for 

each measure the registry wishes to report using a CMS-provided measure flow, and 5 hours to 

complete an XML submission – to become qualified to report Physician Quality Reporting 

System quality measures data. Therefore, we estimate that it would cost a registry approximately 

($16.00/hour x 10 hours) $160 to become qualified to submit Physician Quality Reporting 

System quality measures data on behalf of its eligible professionals. 

With respect to the reporting of quality measures data, we believe the burden associated 

with reporting is the time and effort associated with the registry calculating quality measures 

results from the data submitted to the registry by its eligible professionals, submitting numerator 

and denominator data on quality measures, and calculating these measure results. We believe, 

however, that registries already perform these functions for its eligible professionals irrespective 
CMS-1590-P 712 

of participating in the Physician Quality Reporting System. Therefore, we believe there would 

be little to no additional burden associated with reporting Physician Quality Reporting System 

quality measures data. Whether there is any additional reporting burden will vary with each 

registry, depending on the registry’s level of savvy with submitting quality measures data for the 

Physician Quality Reporting System. 

 With respect to EHR products, the total burden for direct EHR products and EHR data 

submission vendors who submit Physician Quality Reporting System Quality Measures Data 

would be the time and effort associated with submitting this data. To submit quality measures 

data for the proposed program years under the Physician Quality Reporting System, a direct 

EHR product or EHR data submission vendor would need to report quality measures data on 

behalf of its eligible professionals. Please note that we are not proposing to continue to require 

direct EHR products and EHR data submission vendors to become qualified to submit Physician 

Quality Reporting System quality measures data. With respect to reporting quality measures 

data, we believe the burden associated with the EHR vendor programming its EHR product(s) to 

extract the clinical data that the eligible professional must submit to CMS would depend on the 

vendor’s familiarity with the Physician Quality Reporting System and the vendor’s system and 

programming capabilities. We believe it would take a vendor approximately 40 hours (for 

experienced vendors) to 200 hours (for first-time vendor participants) to submit Physician 

Quality Reporting System quality measures data. Therefore, we estimate that it would cost an 

EHR vendor ($40/hour x 40 hours) $1,600 to $8,000 to submit Physician Quality Reporting 

System quality measures data for its eligible professionals. 

TABLE 91: Estimated Costs for Reporting Physician Quality Reporting System Quality 

Measures Data for Eligible Professionals 

 Estimated 

Hours 

Estimated 

Cases 

Number of 

Measures 

Hourly 

Rate 

Total 

Cost 

Individual Eligible Professional 5.0 1 N/A $16 $80 
CMS-1590-P 713 

 Estimated 

Hours 

Estimated 

Cases 

Number of 

Measures 

Hourly 

Rate 

Total 

Cost 

(EP): Preparation 

Individual EP: Claims 0.2 6 3 $40 $144 

Individual EP: Administrative 

Claims 

2 1 N/A $16 $32 

Individual EP: Registry N/A 1 N/A N/A Minimal

Individual EP: EHR N/A 1 N/A N/A Minimal

Group Practice: Self-Nomination 6.0 1 N/A $16 $96 

Group Practice: Reporting 79 1 N/A $40 $3,160 

TABLE 92: Estimated Costs to Vendors to Participate in the Physician Quality Reporting 

System 

 Estimated Hours Hourly Rate Total Cost 

Registry: Self-Nomination 10 $40 $400 

EHR: Programming 40-200 $40 $1,600 - $1,800 

8. Electronic Prescribing (eRx) Incentive Program 

 Please note that the requirements for becoming a successful electronic prescriber for the 

2013 incentive and 2014 payment adjustment were established in the CY 2012 MPFS final rule 

with comment period. The proposed provisions contained in this CY 2013 MPFS proposed rule 

would make additional changes to the requirements for the 2013 incentive and 2014 payment 

adjustment for group practices. Specifically, CMS is proposing to add a new criterion for being 

a successful electronic prescriber for the 2013 incentive and 2014 payment adjustments for group 

practices of 2-24 eligible professionals given that CMS is proposing to modify the definition of 

group practice. However, we note that any additional impact a result of this proposal would be 

minimal, as it is our understanding the eligible professionals who would use this new reporting 

option are already participating in the eRx Incentive Program as individual eligible professionals. 

 For the reasons stated, the proposals would have no additional impact other than the 

impact of the 2013 and 2014 payment adjustments described in the CY 2012 MPFS final rule 

with comment period. 

9. Medicare Shared Savings Program 
CMS-1590-P 714 

 Please note that the requirements for participating in the Medicare Shared Saving 

Program and the impacts of these requirements were established in the final rule for the 

Medicare Shared Savings Program that appeared in the Federal Register on November 2, 2011 

(76 FR 67962). The proposals for the Medicare Shared Savings Program set forth in the CY 

2013 MPFS proposed rule impose requirements that eligible professionals in group practices 

within accountable care organizations would need to satisfy for purposes of the PQRS payment 

adjustment under the Medicare Shared Savings Program as the proposals related to the ACOs for 

the PQRS payment adjustment mirror the requirements that were established for earning the 

PQRS incentives. 

10. Medicare EHR Incentive Program 

 Please note that the requirements for reporting clinical quality measures (CQMs) to 

achieve meaningful use under Stage 1 for the EHR Incentive Program were established in a 

standalone final rule published on July 28, 2010 (75 FR 44544). The proposals contained in this 

CY 2013 MPFS proposed rule merely propose methods to report CQMs to meet the CQM 

objective for achieving meaningful use under Stage 1 for the EHR Incentive Program. 

Therefore, the impacts to the proposal we are making to extend the use of attestation and the 

Physician Quality Reporting System-Medicare EHR Incentive Pilot to report CQMs were 

absorbed in the impacts discussion published in the EHR Incentive Program final rule published 

on July 28, 2010. 

11. Chiropractic Services Demonstration 

As discussed in section III of this rule with comment period, we are continuing the 

recoupment of the $50 million in expenditures from this demonstration in order to satisfy the BN 

requirement in section 651(f)(1)(B) of the MMA. We initiated this recoupment in CY 2010 and 

this will be the fourth year. As discussed in the CY 2010 PFS final rule with comment period, 
CMS-1590-P 715 

we finalized a policy to recoup $10 million each year through adjustments to the PFS for all 

chiropractors in CY s 2010 through 2014. To implement this required BN adjustment, we are 

recouping $10 million in CY 2013 by reducing the payment amount under the PFS for the 

chiropractic CPT codes (that is, CPT codes 98940, 98941, and 98942) by approximately 

2 percent. 

11. Physician Value-Based Payment Modifier and the Physician Feedback Reporting Program 

The proposed changes to the Physician Feedback Program in section IV.I. of this 

proposed rule would not impact CY 2013 physician payments under the PFS. However, we 

expect that our proposals to use the Physician Quality Reporting System (PQRS) quality 

measures in the Physician Feedback reports and in the value modifier to be implemented in 

CY 2015 may result in increased participation in the PQRS in CY 2013. We anticipate that as 

we approach implementation of the value modifier, physicians will increasingly participate in the 

PQRS to determine and understand how the value modifier could affect their payments. 

12. Medicare Coverage of Hepatitis B Vaccine: Modification of high risk groups eligible for 

Medicare Part B coverage of Hepatitis B vaccine. 

As discussed in section III of this proposed rule, section 1861(s)(10)(B) of the Act 

authorizes Medicare coverage of hepatitis B vaccine and its administration if furnished to an 

individual who is at high or intermediate risk of contracting hepatitis B, as determined by the 

Secretary under regulations. Our current regulations are established at 42 CFR §410.63. We are 

proposing to modify §410.63(a)(1) by adding persons diagnosed with diabetes mellitus to the 

high risk group. While it is estimated that approximately 23 percent of non-institutionalized 

Medicare beneficiaries are diagnosed with diabetes mellitus, it is unclear how many of these 

beneficiaries will obtain these services. Therefore, the estimated impact of adding persons 
CMS-1590-P 716 

diagnosed with diabetes mellitus to the high risk group eligible for coverage of hepatitis B 

vaccine and its administration is unknown for CY 2013. 

13. Existing Standards for E-prescribing under Medicare Part D and Identification and Lifting 

the LTC Exemption 

The e-prescribing standard updates that are proposed in this section of the proposed rule 

imposes no new requirements as the burden in using the updated standards is anticipated to be 

the same as using the old standards. We believe that prescribers and dispensers that are now eprescribing largely invested in the hardware, software, and connectivity necessary to e-prescribe. 

We do not anticipate that the retirement of NCPDP SCRIPT 8.1 in favor of NCPDP SCRIPT 

10.6 will result in significant costs. We also believe the same holds true for the standard updates 

for NCPDP Formulary and Benefits 3.0. The backward compatible Formulary and Benefits 3.0 

imposes no new requirements on entities that are already e-prescribing. Entities that choose to 

use Formulary and Benefits 3.0 would be doing so voluntarily. 

The proposed removal of the LTC exception to the NCPDP SCRIPT standard would 

impose a small burden on the LTC industry. LTC entities who use and developed proprietary 

solutions may need to invest in software programming updates if they had not already 

incorporated the Part D e-prescribing standards in their solutions. It is reasonable to assume that 

a small number of proprietary solutions would have to modify their software in order to adhere to 

the adopted e-prescribing standards. Other cost may be incurred though staff training on the use 

of the e-prescribing standards and the use of an e-prescribing solution if adopted by a LTC 

facility. Additional training cost may involve prescribers and dispensers learning the new 

workflows that an electronic prescription may or may not require. 

I. Alternatives Considered
CMS-1590-P 717 

 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. 

J. 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 value-based payment modifier to adjust physician payment 

beginning in CY 2015; creating a separate payment for post-discharge transitional care 

management services in the 30 days after a beneficiary has been discharged from an inpatient 

hospital admission, from outpatient observation services and partial hospitalization program,, 

from a SNF, or from a CMHC; improved accuracy in payment through revisions to the inputs 

used to calculate payments under the PFS for certain radiation therapy services; capital interest 

rate assumptions; multiple procedure payment reduction for ophthalmology and cardiovascular 

diagnostic tests; and revisions to payment for Part B drugs will have a positive impact and 

improve the quality and value of care furnished to Medicare beneficiaries. 

 Most of the aforementioned proposed policy changes could result in a change in 

beneficiary liability as it 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 85, the CY 2012 national payment amount in the nonfacility setting 

for CPT code 99203 (Office/outpatient visit, new) is $105.18 which means that in CY 2012 a 

beneficiary would be responsible for 20 percent of this amount, or $21.04. Based on this 

proposed rule, using the current (CY 2012) CF of 34.0376, the CY 2013 national payment 
CMS-1590-P 718 

amount in the nonfacility setting for CPT code 99203, as shown in Table 85, is $106.31, which 

means that, in CY 2013, the proposed beneficiary coinsurance for this service would be $21.26 

K. Accounting Statement

As required by OMB Circular A-4 (available at 

http://www.whitehouse.gov/omb/circulars/a004/a-4.pdf), in Table 93 (Accounting Statement), 

we have prepared an accounting statement showing the estimated expenditures associated with 

this proposed rule. This estimate includes the estimated FY 2012 cash benefit impact associated 

with certain Affordable Care Act and MCTRJCA provisions, and the CY 2013 incurred benefit 

impact associated with the estimated CY 2013 PFS conversion factor update based on the MidSession Review of the FY 2013 President's Budget baseline. 

TABLE 93: Accounting Statement: Classification of Estimated Expenditures 

CATEGORY TRANSFERS 

CY 2013 Annualized Monetized Transfers Estimated decrease in expenditures of $23.5 billion 

for PFS conversion factor update 

From Whom To Whom? Federal Government to physicians, other 

practitioners and providers and suppliers who receive 

payment under Medicare. 

CY 2013 Annualized Monetized Transfers Estimated increase in payment of 162 millions 

From Whom To Whom? Federal Government to eligible professionals 

participated in (Physician Quality Reporting System 

(PQRS) 

TABLE 94: Accounting Statement: 

Classification of Estimated Costs, Transfer, and Savings ($ In Millions) 
CMS-1590-P 719 

CATEGORY BENEFIT 

Qualitative (unquantified) benefits of fraud, 

waste, and abuse prevented, and of improved 

quality of services to patients improved 

quality of services to patients

No precise estimate available

CATEGORY COST 

CY 2013 Annualized monetized costs of 

beneficiary travel time

$9.37 millions

CATEGORY TRANSFER

CY 2013 Annualized Monetized Transfers of 

beneficiary cost coinsurance

$10 millions

From Whom To Whom? Beneficiaries to Federal Government

CATEGORY TRANSFER

CY 2013 Medicare face-to-face visit and Gcode payments$16.2 millions

From Whom To Whom? Federal Government to DME providers

L. 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 

remainder 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. 
CMS-1590-P 720 

 

List of Subjects 

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 415 

Health facilities, Health professions, Medicare, Reporting and recordkeeping 

requirements. 

42 CFR Part 421

Administrative practice and procedure, Health facilities, Health professions, Medicare, 

Reporting and recordkeeping requirements. 

42 CFR Part 423

Administrative practice and procedure, Emergency medical services, Health facilities, 

Health maintenance organizations (HMO). Health professionals, Medicare, Penalties, Privacy, 

Reporting and recordkeeping requirements. 

42 CFR Part 425

Administrative practice and procedure, Health facilities, Health professions, Medicare, 

Reporting and recordkeeping requirements. 

42 CFR Part 486 

Grant programs-health, Health facilities, Medicare, Reporting and recordkeeping 

requirements, X-rays. 

42 CFR Part 495
CMS-1590-P 721 

 

Administrative practice and procedure, Electronic health records, Health facilities, Health 

professions, Health maintenance organizations (HMO), Medicaid, Medicare, Penalties, Privacy, 

Reporting and recordkeeping requirements. 
CMS-1590-P 722 

 

For the reasons set forth in the preamble, the Centers for Medicare & Medicaid Services 

propose to amend 42 CFR chapters IV as set forth below: 

PART 410--SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS 

1. 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. 

2. Section 410.32 is amended by-- 

A. Revising paragraphs (b)(2)(iii) introductory text, (d)(2)(i), and (e). 

B. Redesignating paragraphs (c)(2) and (c)(3) as paragraphs (c)(3) and (c)(4), 

respectively. 

C. Adding new paragraph (c)(2) 

The revisions and addition read as follows: 

§ 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: 

Conditions. 

* * * * * 

(b) * * * 

(2) * * * 

(iii) Diagnostic psychological and neuropsychological testing services when— 

* * * * * 

(c) * * * 

(2) These services are ordered by a physician as provided in (a) or by a nonphysician 

practitioner as provided in (a)(2) of this section. 

(d) * * * 

(2) * * * 
CMS-1590-P 723 

 

(i) Ordering the service. The physician or (qualified nonphysican practitioner, as defined 

in paragraph (a)(2) of this section), who orders the service must maintain documentation of 

medical necessity in the beneficiary's medical record. 

* * * * * 

(e) Diagnostic laboratory tests furnished in hospitals and CAHs. The provisions of 

paragraphs (a) and (d)(2) through (d)(4) of this section, inclusive, of this section apply to all 

diagnostic laboratory test furnished by hospitals and CAHs to outpatients. 

§410.37 [Amended] 

3. Amend §410.37 by-- 

A. Revising paragraph (a)(1)(iii) by removing the phrase “In the case of an individual at 

high risk for colorectal cancer,”. 

B. Removing paragraph (g)(1). 

C. Redesignating paragraphs (g)(2) through (g)(4) as paragraph (g)(1) through (g)(3), 

respectively. 

D. In newly redesignated paragraph (g)(1), removing the reference “(g)(4)” and adding 

in its place the reference “(g)(3)”. 

4. Section 410.38 is amended by revising paragraph (g) to read as follows: 

§410.38 Durable medical equipment: Scope and conditions. 

 * * * * * 

(g)(1) Items requiring a written order. As a condition of payment, Specified Covered 

Items (as described in paragraph (g)(2) of this section) require a written order that meets the 

requirements in paragraphs (g)(3) and (4) of this section before delivery of the item. 

(2) Specified covered items. (i) Specified Covered Items are items of durable medical 

equipment that CMS has specified in accordance with section 1834(a)(11)(B)(i) of the Act. A 
CMS-1590-P 724 

 

list of these items is updated annually in the Federal Register. 

(ii) The list of Specified Covered Items includes the following: 

 (A) Any item described by a Healthcare Common Procedure Coding System (HCPCS)

code for the following types of durable medical equipment: 

(1) Transcutaneous electrical nerve stimulation (TENS) unit. 

(2) Rollabout chair. 

(3) Wheelchair accessories. 

(4) Oxygen and respiratory equipment. 

(5) Hospital beds and accessories. 

(6) Traction-cervical. 

(B) Any item of durable medical equipment that appears on the Durable Medical 

Equipment, Prosthetics, Orthotics, and Supplies Fee Schedule with a price ceiling at or greater 

than $1,000. 

(C) Any other item of durable medical equipment that CMS adds to the list of Specified 

Covered Items through the notice and comment rulemaking process in order to reduce the risk of 

fraud, waste, and abuse. 

(iii) The list of specific covered items excludes the following: 

(A) Any item that is no longer covered by Medicare. 

(B) Any HCPCS code that is discontinued. 

(3) Face-to-face encounter requirements. (i) For orders issued in accordance with 

paragraphs (g)(1) and (2) of this section, as a condition of payment for the Specified Covered 

Item, all of the following must occur: 

(A) The physician must document and communicate to the DME supplier that the 

physician or a physician assistant, a nurse practitioner, or a clinical nurse specialist has had a 
CMS-1590-P 725 

 

face-to-face encounter with the beneficiary on the date of the written order or during either of the 

following: 

(1) Up to 90 days before the date of the written order. 

(2) Within 30 days after the date that the order is written. 

(B) During the face-to-face encounter the physician, a physician assistant, a nurse 

practitioner, or a clinical nurse specialist must conduct a needs assessment, evaluate, or treat the 

beneficiary for the medical condition that supports the need for each covered item of DME 

ordered. 

(C) The face-to-face encounter must be documented in the pertinent portion of the 

medical record (for example, history, physical examination, diagnostic tests, summary of 

findings, diagnoses, treatment plans or other information as it may be appropriate). 

(i) For purposes of paragraph (g), a face-to-face encounter does not include DME items 

and services furnished from an "incident to" service. 

(ii) For purposes of paragraph (g), a face-to-face beneficiary encounter may occur via 

telehealth in accordance with all of the following: 

(A) Section 1834(m) of the Act. 

(B)(1) Medicare telehealth regulations in §410.78 and §414.65 of this chapter; and 

(2) Subject to the list of payable Medicare telehealth services established by the 

applicable PFS. 

(4) Written order issuance requirements. Written orders issued in accordance with 

paragraphs (g)(1) and (2) of this section must include all of the following: 

(i) Beneficiary's name. 

(ii) Item of DME ordered. 

(iii) Prescribing practitioner NPI. 
CMS-1590-P 726 

 

(iv) Signature of the prescribing practitioner. 

(v) The date of the order. 

(vi) The beneficiary's diagnosis. 

(vii) Necessary proper usage instructions, as applicable 

(5) Supplier's order and documentation requirements. (i) A supplier must maintain the 

written order and the supporting documentation provided by the physician, physician assistant, 

nurse practitioner, or clinical nurse specialist and make them available to CMS upon request for 

7 years from the date of service consistent with §424.516(f) of this chapter. 

 (ii) Upon request by CMS or its agents, a supplier must submit additional documentation 

to CMS or its agents to support and substantiate that a face-to-face encounter has occurred. 

5. Section 410.40 is amended by-- 

A. In paragraph (c)(3)(ii), the word “fro” is revised to read “from.” 

B. Redesignating paragraph (d)(2) as (d)(2)(i). 

C. Adding paragraph (d)(2)(ii). 

The addition reads as follows: 

§410.40 Coverage of ambulance services. 

* * * * * 

(d) * * * 

(2) * * * 

(ii) In all cases, the provider or supplier must keep appropriate documentation on file and, 

upon request, present it to the contractor. The presence of the signed physician certification 

statement does not alone demonstrate that the ambulance transport was medically necessary. All 

other program criteria must be met in order for payment to be made. 

* * * * * 
CMS-1590-P 727 

 

6. Section 410.59 is amended by adding paragraph (a)(4) to read as follows: 

§410.59 Outpatient occupational therapy services: Conditions. 

(a) * * * 

(4) Claims submitted for furnished services contain prescribed information on patient 

functional limitations. 

* * * * * 

7. Section 410.60 is amended by adding paragraph (a)(4) to read as follows: 

§ 410.60 Outpatient physical therapy services: Conditions. 

(a) * * * 

(4) Claims submitted for furnished services contain prescribed information on patient 

functional limitations. 

* * * * * 

8. Section 410.61 is amended by revising paragraph (c) to read as follows: 

§410.61 Plan of treatment requirements for outpatient rehabilitation services. 

* * * * * 

(c) Content of the plan. The plan prescribes the type, amount, frequency, and duration of 

the physical therapy, occupational therapy, or speech-language pathology services to be 

furnished to the individual, and indicates the diagnosis and anticipated goals that are consistent 

with the patient function reporting on claims for services. 

* * * * * 

9. Section 410.62 is amended by adding paragraph (a)(4) to read as follows: 

§ 410.62 Outpatient speech-language-pathology services: Conditions and exclusions. 

 (a) * * * 

(4) Claims submitted for furnished services contain prescribed information on patient 
CMS-1590-P 728 

 

functional limitations. 

* * * * * 

10. Section 410.63 is amended by adding paragraph (a)(1)(viii) to read as follows: 

§410.63 Hepatitis B vaccine and blood clotting factors: Conditions. 

* * * 

(a) * * * 

(1) * * * 

(viii) Persons diagnosed with diabetes mellitus. 

* * * * * 

11. Section 410.69 is amended by adding the definition “Anesthesia and related care” to 

paragraph (b) in alphabetical order to read as follows: 

§410.69 Services of a certified registered nurse anesthetist or an anesthesiologist’s assistant: 

Basic rule and definitions. 

* * * * * 

(b) * * * 

Anesthesia and related care includes medical and surgical services that are related to 

anesthesia and that a CRNA is legally authorized to perform by the state in which the services 

are furnished. 

* * * * * 

12. Section 410.78 is amending by revising the introductory text of paragraph (b) to read 

as follows: 

§410.78 Telehealth services. 

* * * * * 
CMS-1590-P 729 

 

(b) General rule. Medicare Part B pays for office or other outpatient visits, subsequent 

hospital care services (with the limitation of one telehealth visit every three days by the patient’s 

admitting physician or practitioner), subsequent nursing facility care services (not including the 

Federally-mandated periodic visits under §483.40(c) and with the limitation of one telehealth 

visit every 30 days by the patient’s admitting physician or nonphysician practitioner), 

professional consultations, psychiatric diagnostic interview examination, neurobehavioral status 

exam, individual psychotherapy, pharmacologic management, end-stage renal disease-related 

services included in the monthly capitation payment (except for one “hands on” visit per month 

to examine the access site), individual and group medical nutrition therapy services, individual 

and group kidney disease education services, individual and group diabetes self-management 

training services (except for one hour of “hands on” services to be furnished in the initial year 

training period to ensure effective injection training), individual and group health and behavior 

assessment and intervention services, smoking cessation services, alcohol and/or substance abuse 

and brief intervention services, screening and behavioral counseling interventions in primary 

care to reduce alcohol misuse, screening for depression in adults, screening for sexually 

transmitted infections (STIs) and high intensity behavioral counseling (HIBC) to prevent STIs, 

intensive behavioral therapy for cardiovascular disease, and behavioral counseling for obesity 

furnished by an interactive telecommunications system if the following conditions are met: 

* * * * * 

13. Section 410.105 is amended by-- 

A. Revising paragraph (c)(1)(ii). 

B. Adding new paragraph (d). 

The revision and addition read as follows: 

§410.105 Requirement for coverage of CORF services. 
CMS-1590-P 730 

 

* * * * * 

(c) * * * 

(1) * * * 

(ii) Prescribes the type, amount, frequency, and duration of the services to be furnished, 

and indicates the diagnosis and anticipated rehabilitation goals that are consistent with the patient 

function reporting on the claims for services. 

* * * * * 

(d) Claims submitted for physical therapy, occupational therapy or speech-languagepathology services, contain prescribed information on patient functional limitations. 

14. Section 410.160 is amended by-- 

A. Redesignating paragraphs (b)(8) through (b)(13) as paragraphs (b)(9) through (b)(14). 

B. Adding new paragraph (b)(8). 

The addition reads as follows: 

§410.160 Part B annual deductible. 

* * * * * 

(b) * * * 

(8) Beginning January 1, 2011, a surgical service furnished in connection with, as a 

result of, and in the same clinical encounter as a planned colorectal screening test. A surgical 

service furnished in connection with, as a result of, and in the same clinical encounter as a 

colorectal screening test means —a surgical service furnished on the same date as a planned 

colorectal cancer screening test as described in §410.37 of this part. 

* * * * * 

PART 414--PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES 

15. The authority citation for part 414 continues to read as follows: 
CMS-1590-P 731 

 

Authority: Secs. 1102, 1871, and 1881(b)(l) of the Social Security Act (42 U.S.C. 1302, 

1395hh, and 1395rr(b)(l)). 

16. Section 414.65 is amended by revising paragraph (a)(1) to read as follows: 

§414.65 Payment for telehealth services. 

(a) * * * 

(1) The Medicare payment amount for office or other outpatient visits, subsequent 

hospital care services (with the limitation of one telehealth visit every 3 days by the patient’s 

admitting physician or practitioner), subsequent nursing facility care services (with the limitation 

of one telehealth visit every 30 days by the patient’s admitting physician or nonphysician 

practitioner), professional consultations, psychiatric diagnostic interview examination, 

neurobehavioral status exam, individual psychotherapy, pharmacologic management, end-stage 

renal disease-related services included in the monthly capitation payment (except for one “hands 

on” visit per month to examine the access site), individual and group medical nutrition therapy 

services, individual and group kidney disease education services, individual and group diabetes 

self-management training services (except for one hour of “hands on” services to be furnished in 

the initial year training period to ensure effective injection training), individual and group health 

and behavior assessment and intervention, smoking cessation services, alcohol and/or substance 

abuse and brief intervention services, screening and behavioral counseling interventions in 

primary care to reduce alcohol misuse, screening for depression in adults, screening for sexually 

transmitted infections (STIs) and high intensity behavioral counseling (HIBC) to prevent STIs, 

intensive behavioral therapy for cardiovascular disease, and behavioral counseling for obesity 

furnished via an interactive telecommunications system is equal to the current fee schedule 

amount applicable for the service of the physician or practitioner. 
CMS-1590-P 732 

 

(i) Emergency department or initial inpatient telehealth consultations. The Medicare 

payment amount for emergency department or initial inpatient telehealth consultations furnished 

via an interactive telecommunications system is equal to the current fee schedule amount 

applicable to initial hospital care provided by a physician or practitioner. 

(ii) Follow-up inpatient telehealth consultations. The Medicare payment amount for 

follow-up inpatient telehealth consultations furnished via an interactive telecommunications 

system is equal to the current fee schedule amount applicable to subsequent hospital care 

provided by a physician or practitioner. 

* * * * * 

17. Section 414.90 is amended by-- 

A. In paragraph (b), revising the definitions “Group practice” and “Qualified registry.” 

B. Removing the term “Qualified electronic health record product”. 

C. Adding the definitions “Administrative claims,” “Direct electronic health record 

(EHR) product,” “Electronic health record (EHR) data submission vendor product,” and “Group 

practice reporting option (GPRO) web-interface” in alphabetical order. 

D. Revising paragraphs (c) and (d). 

E. Redesignating paragraphs (e), (f), (g), (h), (i), and (j) as paragraphs (f), (g), (i), (j), (k), 

and (l), respectively. 

F. Adding new paragraphs (e) and (h). 

G. Revising newly designated paragraphs (f), (g), and (k). 

The revisions and additions read as follows: 

§414.90 Physician Quality Reporting System. 

* * * * * 

(b) * * * 
CMS-1590-P 733 

 

Administrative claims means a reporting mechanism under which an eligible professional 

or group practice uses claims to report data on the proposed PQRS quality measures. Under this 

reporting mechanism, CMS determines which measures an eligible professional or group 

practice reports. 

Direct electronic health record (EHR) product means an electronic health record vendor's 

product and version that submits data on Physician Quality Reporting System measures directly 

to CMS. 

Electronic health record (EHR) data submission vendor product means an electronic 

health record vendor’s product or version that acts as an intermediary to submit data on 

Physician Quality Reporting System measures on behalf of an eligible professional or group 

practice. 

* * * * * 

Group practice means a physician group practice that is defined by a TIN, with 2 or more 

individual eligible professionals (or, as identified by NPIs) that has reassigned their billing rights 

to the TIN. 

Group practice reporting option (GPRO) web-interface means a web product developed 

by CMS that is used by group practices that are selected to participate in the group practice 

reporting option (GPRO) to submit data on Physician Quality Reporting System quality 

measures. 

* * * * * 

Qualified registry means a medical registry or a maintenance of certification program 

operated by a specialty body of the American Board of Medical Specialties that, with respect to a 

particular program year, has self-nominated and successfully completed a vetting process (as 

specified by CMS) to demonstrate its compliance with the Physician Quality Reporting System 
CMS-1590-P 734 

 

qualification requirements specified by CMS for that program year. The registry may act as a 

data submission vendor, which has the requisite legal authority to provide Physician Quality 

Reporting System data (as specified by CMS) on behalf of an eligible professional to CMS. If 

CMS finds that a qualified registry submits grossly inaccurate data for reporting periods 

occurring in a particular year, CMS reserves the right to disqualify a registry for reporting 

periods occurring in the following year. 

* * * * * 

 (c) Incentive payments. For 2007 to 2014, with respect to covered professional services 

furnished during a reporting period by an eligible professional, an eligible professional (or in the 

case of a group practice under paragraph (i) of this section, a group practice) may receive an 

incentive if -- 

(1) There are any quality measures that have been established under the Physician 

Quality Reporting System that are applicable to any such services furnished by such professional 

(or in the case of a group practice under paragraph (i) of this section, such group practice) for 

such reporting period; and 

(2) If the eligible professional (or in the case of a group practice under paragraph (j) of 

this section, the group practice) satisfactorily submits (as determined under paragraph (g) of this 

section for the eligible professional and paragraph (i of this section for the group practice) to the 

Secretary data on such quality measures in accordance with the Physician Quality Reporting 

System for such reporting period, in addition to the amount otherwise paid under section 1848 of 

the Act, there also must be paid to the eligible professional (or to an employer or facility in the 

cases described in section 1842(b)(6)(A) of the Act or, in the case of a group practice under 

paragraph (i) of this section, to the group practice) from the Federal Supplementary Medical 

Insurance Trust Fund established under section 1841 of the Act an amount equal to the 
CMS-1590-P 735 

 

applicable quality percent (as specified in paragraph (c)(3) of this section) of the eligible 

professional's (or, in the case of a group practice under paragraph (i) of this section, the group 

practice's) total estimated allowed charges for all covered professional services furnished by the 

eligible professional (or, in the case of a group practice under paragraph (i) of this section, by the 

group practice) during the reporting period. 

(3) The applicable quality percent is as follows: 

(i) For 2007 and 2008, 1.5 percent. 

(ii) For 2009 and 2010, 2.0 percent. 

(iii) For 2011, 1.0 percent. 

(iv) For 2012, 2013, and 2014, 0.5 percent. 

(4) For purposes of this paragraph-- 

(i) The eligible professional's (or, in the case of a group practice under paragraph (i) of 

this section, the group practice's) total estimated allowed charges for covered professional 

services furnished during a reporting period are determined based on claims processed in the 

National Claims History (NCH) no later than 2 months after the end of the applicable reporting 

period; 

(ii) In the case of the eligible professional who furnishes covered professional services in 

more than one practice, incentive payments are separately determined for each practice based on 

claims submitted for the eligible professional for each practice; 

(iii) Incentive payments to a group practice under this paragraph must be in lieu of the 

payments that would otherwise be made under the Physician Quality Reporting System to 

eligible professionals in the group practice for meeting the criteria for satisfactory reporting for 

individual eligible professionals. For any program year in which the group practice (as identified 

by the TIN) is selected to participate in the Physician Quality Reporting System group practice 
CMS-1590-P 736 

 

reporting option, the eligible professional cannot individually qualify for a Physician Quality 

Reporting System incentive payment by meeting the requirements specified in paragraph (g) of 

this section. 

(iv) Incentive payments earned by the eligible professional (or in the case of a group 

practice under paragraph (i) of this section, by the group practice) for a particular program year 

will be paid as a single consolidated payment to the TIN holder of record. 

(d) Additional incentive payment. Through 2014, if an eligible professional meets the 

requirements described in paragraph (d)(2) of this section, the applicable percent for such year, 

as described in paragraphs (c)(3)(i) and (ii) of this section, must be increased by 0.5 percentage 

points. 

(1) In order to qualify for the additional incentive payment described in paragraph (d)(1) 

of this section, an eligible professional must meet all of the following requirements: 

(i) Satisfactorily submits data on quality measures for purposes of this section for the 

applicable incentive year. 

(ii) Have such data submitted on their behalf through a Maintenance of Certification 

program (as defined in paragraph (b) of this section) that meets: 

(A) The criteria for a registry (as specified by CMS); or 

(B) An alternative form and manner determined appropriate by the Secretary. 

(iii) The eligible professional, more frequently than is required to qualify for or maintain 

board certification status— 

(A) Participates in a maintenance of certification program (as defined in paragraph (b) of 

this section) for a year; and 

(B) Successfully completes a qualified maintenance of certification program practice 

assessment (as defined in paragraph (b) of this section) for such year. 
CMS-1590-P 737 

 

(2) In order for an eligible professional to receive the additional incentive payment, a 

Maintenance of Certification Program must submit to the Secretary, on behalf of the eligible 

professional, information— 

(i) In a form and manner specified by the Secretary, that the eligible professional has 

successfully met the requirements of paragraph (d)(2)(ii) of this section, which may be in the 

form of a structural measure. 

(ii) If requested by the Secretary, on the survey of patient experience with care. 

(iii) As the Secretary may require, on the methods, measures, and data used under the 

Maintenance of Certification Program and the qualified Maintenance of Certification Program 

practice assessment. 

(e) Payment Adjustments. For 2015 and subsequent years, with respect to covered 

professional services furnished by an eligible professional, if the eligible professional does not 

satisfactorily submit data on quality measures for covered professional services for the quality 

reporting period for the year (as determined under section 1848(m)(3)(A) of the Act), the fee 

schedule amount for such services furnished by such professional during the year (including the 

fee schedule amount for purposes for 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 under this subsection. 

(1) The applicable percent is as follows: 

(i) For 2015, 98.5 percent; and 

(ii) For 2016 and each subsequent year, 98 percent. 

(2) [Reserved] 

(f) Use of consensus-based quality measures. For measures selected for inclusion in the 

Physician Quality Reporting System quality measure set, CMS will use consensus-based quality 
CMS-1590-P 738 

 

measures that meet one of the following criteria: 

(1) 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. 

(2) 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 entity with a 

contract under section 1890(a) of the Act, the Secretary may 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. 

(3) For each quality measure adopted by the Secretary under this paragraph, the Secretary 

ensures that eligible professionals have the opportunity to provide input during the development, 

endorsement, or selection of quality measures applicable to services they furnish. 

(g) Requirements for the incentive payments. In order to qualify to earn a Physician 

Quality Reporting System incentive payment for a particular program year, an individual eligible 

professional, as identified by a unique TIN/NPI combination, (or in the case of a group practice 

under paragraph (i) of this section, by the group practice) must meet the criteria for satisfactory 

reporting specified by CMS for such year by reporting on either individual Physician Quality 

Reporting System quality measures or Physician Quality Reporting System measures groups 

identified by CMS during a reporting period specified in paragraph (g)(1) of this section and 

using one of the reporting mechanisms specified in paragraph (g)(2) of this section. 

(1) Reporting periods. For purposes of this paragraph, the reporting period is— 

(i) The 12-month period from January 1 through December 31 of such program year. 

(ii) A 6-month period from July 1 through December 31 of such program year. 
CMS-1590-P 739 

 

(A) For 2011, such 6-month reporting period is not available for EHR-based reporting of 

individual Physician Quality Reporting System quality measures. 

(B) For 2012 and subsequent program years, such 6-month reporting period from July 1 

through December 31 of such program year is only available for registry-based reporting of 

Physician Quality Reporting System measures groups by eligible professionals. 

(2) Reporting mechanisms. For program year 2011 and subsequent program years, an 

eligible professional who wishes to participate in the Physician Quality Reporting System must 

report information on the individual Physician Quality Reporting System quality measures or 

Physician Quality Reporting System measures groups identified by CMS in one of the following 

manners: 

(i) Claims. Reporting the individual Physician Quality Reporting System quality 

measures or Physician Quality Reporting System measures groups to CMS, by no later than 2 

months after the end of the applicable reporting period, on the eligible professional's Medicare 

Part B claims for covered professional services furnished during the applicable reporting period. 

 (A) If an eligible professional re-submits a Medicare Part B claim for 

reprocessing, the eligible professional may not attach a G-code at that time for reporting on 

individual Physician Quality Reporting System measures or measures groups. 

(B) [Reserved] 

(ii) Registry. Reporting the individual Physician Quality Reporting System quality 

measures or Physician Quality Reporting System measures groups to a qualified registry (as 

specified in paragraph (b) of this section) in the form and manner and by the deadline specified 

by the qualified registry selected by the eligible professional. The selected registry will submit 
CMS-1590-P 740 

 

information, as required by CMS, for covered professional services furnished by the eligible 

professional during the applicable reporting period to CMS on the eligible professional's behalf. 

 (iii) Direct EHR product. Reporting the individual Physician Quality Reporting System 

quality measures to CMS by extracting clinical data using a secure data submission method, as 

required by CMS, from a direct EHR product (as defined in paragraph (b) of this section) by the 

deadline specified by CMS for covered professional services furnished by the eligible 

professional during the applicable reporting period. 

(iv) EHR data submission vendor. Reporting the individual Physician Quality Reporting 

System quality measures to CMS by extracting clinical data using a secure data submission 

method, as required by CMS, from an EHR data submission vendor product (as defined in 

paragraph (b) of this section) by the deadline specified by CMS for covered professional services 

furnished by the eligible professional during the applicable reporting period. 

(v) Web-interface. For a group practices defined in paragraph (b) of this section, 

reporting individual Physician Quality Reporting System quality measures to CMS using a CMS 

web-interface in the form and manner and by the deadline specified by CMS. 

(3) Although an eligible professional may attempt to qualify for the Physician Quality 

Reporting System incentive payment by reporting on both individual Physician Quality 

Reporting System quality measures and measures groups, using more than one reporting 

mechanism (as specified in paragraph (g)(2) of this section), or reporting for more than one 

reporting period, he or she will receive only one Physician Quality Reporting System incentive 

payment per TIN/NPI combination for a program year.

 (h) Requirements for the payment adjustments. In order to satisfy the requirements for 

the Physician Quality Reporting System payment adjustment for a particular program year, an 

individual eligible professional, as identified by a unique TIN/NPI combination (or in the case of 
CMS-1590-P 741 

 

a group practice under paragraph (i) of this section, by the group practice) must meet the criteria 

for satisfactory reporting specified by CMS for such year by reporting on either individual 

Physician Quality Reporting System measures or Physician Quality Reporting System measures 

groups identified by CMS during a reporting period specified in paragraph (h)(1) of this section 

and using one of the reporting mechanisms specified in paragraph (h)(2) of this section. 

 (1) For purposes of this paragraph, the reporting period for the payment adjustment, with 

respect to a payment adjustment year, is the 12-month period from January 1 through December 

31 that falls two years prior to the year in which the payment adjustment is applied. 

(i) For the 2015 and 2016 PQRS payment adjustments only, an alternative 6-month 

reporting period, from July 1—December 31 that fall two years prior to the year in which the 

payment adjustment is applied, is also available. 

(ii) [Reserved] 

(2) An eligible professional (or in the case of a group practice under paragraph (i) of this 

section, by the group practice) who wishes to participate in the Physician Quality Reporting 

System must report information on the individual Physician Quality Reporting System measures 

or Physician Quality Reporting System measures groups identified by CMS using one of the 

following reporting mechanisms: 

 (i) Claims. Reporting the individual Physician Quality Reporting System quality 

measures or Physician Quality Reporting System measures groups to CMS, by no later than 2 

months after the end of the applicable reporting period, on the eligible professional's Medicare 

Part B claims for covered professional services furnished during the applicable reporting period.

 (A) Medicare Part B claims may not be reprocessed or reopened for the sole purpose or 

reporting on individual Physician Quality Reporting System measures or measures groups. 

(B) [Reserved] 
CMS-1590-P 742 

 

 (ii) Qualified registry. Reporting the individual Physician Quality Reporting System 

quality measures or Physician Quality Reporting System measures groups to a qualified registry 

(as specified in paragraph (b) of this section) in the form and manner and by the deadline 

specified by the qualified registry selected by the eligible professional. The selected registry will 

submit information, as required by CMS, for covered professional services furnished by the 

eligible professional during the applicable reporting period to CMS on the eligible professional's 

behalf. 

 (iii) Direct EHR product. Reporting the individual Physician Quality Reporting System 

quality measures to CMS by extracting clinical data using a secure data submission method, as 

required by CMS, from a direct EHR product (as defined in paragraph (b) of this section) by the 

deadline specified by CMS for covered professional services furnished by the eligible 

professional during the applicable reporting period. 

 (iv) EHR data submission vendor. Reporting the individual Physician Quality Reporting 

System quality measures to CMS by extracting clinical data using a secure data submission 

method, as required by CMS, from an EHR data submission vendor product (as defined in 

paragraph (b) of this section) by the deadline specified by CMS for covered professional services 

furnished by the eligible professional during the applicable reporting period.

 (v) GPRO web-interface. For a group practices defined in paragraph (b) of this section 

that are comprised of 25 or more eligible professionals, reporting individual Physician Quality 

Reporting System quality measures to CMS using a CMS web-interface in the form and manner 

and by the deadline specified by CMS. 

(vi) Administrative claims. For the 2015 and 2016 payment adjustments, reporting 

certain administrative claims individual Physician Quality Reporting System quality measures 

during the applicable reporting period. Eligible professionals and (or in the case of a group 
CMS-1590-P 743 

 

practice under paragraph (i) of this section) that are administrative claims reporters must meet 

the following requirement for the payment adjustment: 

(A) Register to participate in the Physician Quality Reporting System using the 

administrative claims reporting option. 

(B) Reporting Medicare Part B claims data for CMS to determine whether the eligible 

professional or group practice has performed services applicable to certain individual Physician 

Quality Reporting System quality measures. 

(3) Although an eligible professional or group practice may attempt to meet the criteria 

for satisfactory reporting for the Physician Quality Reporting System payment adjustment by 

reporting on individual Physician Quality Reporting System quality measures or measures 

groups using more than one reporting mechanism (as specified in paragraph (h)(2) of this 

section), the eligible professional or group practice must satisfy the criteria for satisfactory 

reporting for the Physician Quality Reporting System payment adjustment under one reporting 

mechanism per TIN/NPI combination for a program year. 

(i) Requirements for group practices. Under the Physician Quality Reporting System, a 

group practice (as defined in paragraph (b) of this section) must meet all of the following 

requirements: 

(1) Meet the participation requirements specified by CMS for the Physician Quality 

Reporting System group practice reporting option. 

(2) Be selected by CMS to participate in the Physician Quality Reporting System group 

practice reporting option. 

(3) Report measures in the form and manner specified by CMS. 

(4) Meet other requirements for satisfactory reporting specified by CMS. 

(5) Meet participation requirements. 
CMS-1590-P 744 

 

 (i) If an eligible professional, as identified by an individual NPI, has reassigned his or 

her Medicare billing rights to a group practice (as identified by the TIN) selected to participate in 

the Physician Quality Reporting System group practice reporting option for a program year, then 

for that program year the eligible professional must participate in the Physician Quality 

Reporting System via the group practice reporting option. 

(ii) If, for the program year, the eligible professional participates in the Physician Quality 

Reporting System as part of a group practice (as identified by the TIN) that is not selected to 

participate in the Physician Quality Reporting System group practice reporting option for that 

program year, then the eligible professional may individually participate and qualify for a 

Physician Quality Reporting System incentive by meeting the requirements specified in 

paragraph (g) of this section under that TIN. 

18. Section 414.92 is amended by -- 

A. Revising paragraphs (c)(2)(ii)(A)(5) and (c)(2)(ii)(A)(6). 

B. Adding paragraph (f)(2)(i)(A) and reserving paragraph (f)(2)(i)(B). 

C. Redesignating paragraph (g) as paragraph (h), and adding new paragraph (g). 

The revision and addition reads as follows: 

§ 414.92 Electronic Prescribing Incentive Program. 

* * * * * 

(c) * * * 

(2) * * * 

(ii) * * * 

(A) * * * 

(5) Eligible professionals who achieve meaningful use during the respective 6 or 12-

month payment adjustment reporting period. 
CMS-1590-P 745 

 

(6) Eligible professionals who have registered to participate in the EHR Incentive 

Program and adopted Certified EHR Technology prior to application of the respective payment 

adjustment. 

* * * * * 

(f) * * * 

(2) * * * 

(i) * * * 

(A) If an eligible professional re-submits a Medicare Part B claim for reprocessing, the 

eligible professional may not attach a G-code at that time for reporting on the electronic 

prescribing measure. 

(B) [Reserved] 

Informal review. Eligible professionals (or in the case of reporting under paragraph (e) of 

this section, group practices) may seek an informal review of the determination that an eligible 

professional (or in the case of reporting under paragraph (e) of this section, group practices) did 

not meet the requirements for the 2013 incentive or the 2013 and 2014 payment adjustments. 

(1) To request an informal review for the 2013 incentive, an eligible professional or 

group practice must submit a request to CMS within 90 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. 

(2) To request an informal review for the 2013 and 2014 payment adjustments, an 

eligible professional or group practices must submit a request to CMS by January 31 of the year 

in which the eligible professional is receiving the applicable payment adjustment. 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. 
CMS-1590-P 746 

 

(3) CMS will provide a written response of CMS’ determination within 90 days of the 

receipt of the request. 

(i) All decisions based on the informal review are final. 

(ii) There is no further review or appeal. 

* * * * * 

19. Section 414.610 is amended by revising paragraphs (c)(1)(ii), (c)(5)(ii), and (h) to 

read as follows: 

§414.610 Basis of payment. 

* * * * * 

(c) * * * 

(1) * * * 

(ii) For services furnished during the period July 1, 2008 through December 31, 2012, 

ambulance services originating in--- 

(A) Urban areas (both base rate and mileage) are paid based on a rate that is 2 percent 

higher than otherwise is applicable under this section; and 

(B) Rural areas (both base rate and mileage) are paid based on a rate that is 3 percent 

higher than otherwise is applicable under this section. 

* * * * * 

(5) * * * 

(ii) For services furnished during the period July 1, 2004 through December 31, 2012, 

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 
CMS-1590-P 747 

 

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. 

* * * * * 

(h) Treatment of certain areas for payment for air ambulance services. Any area that was 

designated as a rural area for purposes of making payments under the ambulance fee schedule for 

air ambulance services furnished on December 31, 2006, must be treated as a rural area for 

purposes of making payments under the ambulance fee schedule for air ambulance services 

furnished during the period July 1, 2008 through December 31, 2012. 

20. Section 414.904 is amended by revising paragraphs (d)(3)(ii), (d)(3)(iii) and 

(d)(3)(iv). 

B. The revisions read as follows: 

§414.904 Average sales price as the basis for payment. 

* * * * * 

(d) * * * 

(3) * * * 

(ii) Payment at 103 percent of the average manufacturer price for a billing code will be 

applied at such times when all of the following criteria are met: 

(A) The threshold for making price substitutions, as defined in paragraph (d)(3)(iii) of 

this section is met. 

(B) 103 percent of the average manufacturer price is less than the 106 percent of the 

average sales price for the quarter in which the substitution would be applied. 

(C) Beginning in 2013, the drug and dosage form described by the HCPCS code is not a 

critical or medically necessary drug identified by the FDA to be in short supply at the time that 

ASP calculations are finalized. 
CMS-1590-P 748 

 

(iii) The applicable percentage threshold for average manufacturer price comparisons is 5 

percent and is reached when-- 

(A) The average sales price for the billing code has exceeded the average manufacturer 

price for the billing code by 5 percent or more in 2 consecutive quarters, or 3 of the previous 4 

quarters immediately preceding the quarter to which the price substitution would be applied; and 

(B) The average manufacturer price for the billing code is calculated using the same set 

of National Drug Codes used for the average sales price for the billing code. 

(iv) The applicable percentage threshold for widely available market price comparisons is 

5 percent.

* * * * * 

21. Subpart N is added to Part 414 to read as follows: 

Subpart N--Value-Based Payment Modifier under the Physician Fee Schedule 

Sec. 

414.1200 Basis and scope. 

414.1205 Definitions. 

414.1210 Application of the value-based payment modifier. 

414.1215 Performance and payment adjustment periods for the value-based payment modifier. 

414.1220 Reporting mechanisms for the value-based payment modifier under the 

physician fee schedule. 

414.1225 Alignment of Physician Quality Reporting System quality measures and quality 

measures for the value-based payment modifier. 

414.1230 Additional measures for groups of physicians. 

414.1235 Cost measures. 

414.1240 Attribution for quality of care and cost measures. 
CMS-1590-P 749 

 

414.1245 Scoring methods for the value-based payment modifier. 

414.1250 Benchmarks for quality of care measures. 

414.1255 Benchmarks for cost measures. 

414.1260 Composite scores. 

414.1265 Reliability of measures. 

414.1270 Payment adjustments. 

414.1275 Payment modifier scoring methodology. 

414.1280 Limitation of review. 

414.1285 Inquiry process. 

Subpart N--Value-Based Payment Modifier under the Physician Fee Schedule 

§ 414.1200 Basis and scope. 

(a) Basis. This part/section 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 under the Medicare physician fee schedule based on the quality of care furnished 

compared to cost during a performance period. 

(b) Scope. This subpart sets forth the following: 

(1) The application of the value-based payment modifier. 

(2) Performance and payment adjustment periods. 

(3) Reporting mechanisms for the value-based payment modifier. 

(4) Alignment of PQRS quality of care measures with the quality composite of the 

value-based payment modifier. 

(5) Additional measures for groups of physicians. 

(6) Cost measures. 

(7) Attribution for quality of care and cost measures. 
CMS-1590-P 750 

 

(8) Scoring methods for the value-based payment modifier. 

(9) Benchmarks for quality of care measures. 

(10) Benchmarks for cost measures. 

(11) Composite scores. 

(12) Reliability of measures. 

(13) Payment adjustments. 

(14) Payment modifier scoring methodology. 

(15) Limitation of review. 

(16) Inquiry process. 

§ 414.1205 Definitions.

As used in this section, unless otherwise indicated— 

Accountable care organization (ACO) has the same meaning given this term under 

§425.20 of this chapter. 

Critical access hospital has the same meaning given this term under §400.202 of this 

chapter. 

Electronic health record (EHR) has the same meaning given this term under §414.92 of 

this chapter. 

Eligible professional has the same meaning given this term under section1848(k)(5)(B) 

of the Act. 

Federally Qualified Health Center has the same meaning given this term under 

§405.2401(b) of this chapter. 

Group of physicians means a single Tax Identification Number (TIN) with 2 or more 

eligible professionals, as identified by their individual National Provider Identifier (NPI), who 
CMS-1590-P 751 

 

have reassigned their Medicare billing rights to the TIN, as determined at the time the group of 

physicians is selected to participate under the Physician Quality Reporting System GPRO. 

Performance rate mean the calculated rate for each quality or cost measure such as 

the percent of times that a particular clinical quality action was reported as being performed, or 

a particular outcome was attained, for the applicable persons to whom a measure applies as 

described in the denominator for the measure. 

Physician has the same meaning given this term under section 1861(r) of the Act. 

Physician Fee Schedule has the same meaning given this term under part 410 of this 

chapter. 

Physician Quality Reporting System means the system established under section 1848(k) 

of the Act. 

Risk score means the beneficiary risk score derived from the CMS Hierarchical 

Condition Categories (HCC) model.

Taxpayer Identification Number (TIN) has the same meaning given this term under 

§425.20 of this chapter. 

Value-based payment modifier means the percentage by which amounts paid to a 

physician or group of physicians under the physician fee schedule are adjusted. 

Value-based payment modifier satisfactory reporting criteria means the criteria for 

satisfactory reporting of data on Physician Quality Reporting System quality measures for the 

2013 and 2014 incentive or the criteria for satisfactory reporting using the Physician Quality 

Reporting System administrative claims-based reporting mechanism, which is applicable to the 

2015 and 2016 PQRS payment adjustment. 

§ 414.1210 Application of the value-based payment modifier. 

(a) The value-based payment modifier is applicable to the items and services furnished 
CMS-1590-P 752 

 

under the Medicare Part B physician fee schedule by physicians in groups of physicians with 25 

or more eligible professionals starting on January 1, 2015. 

(b) Exceptions: 

(1) Groups of physicians with 25 or more eligible professionals that are participating in 

the Medicare Shared Savings Program or the Pioneer ACO program. 

(2) [Reserved] 

§ 414.1215 Performance and payment adjustment periods for the value-based payment 

modifier.

(a) The performance period is calendar year 2013 for payment adjustments to be made in 

the calendar year 2015 payment adjustment period. 

(b) The performance period is calendar year 2014 for payment adjustments to be made 

in the calendar year 2016 payment adjustment period. 

§ 414.1220 Reporting mechanisms for the value-based payment modifier under the 

physician fee schedule. 

Groups of physicians may submit data on quality of care measures as specified under the 

Physician Quality Reporting System and in § 414.90(g). 

§ 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 groups of physicians are eligible to report under 

the Physician Quality Reporting System starting in 2013 are used to calculate the value-based 

payment modifier program to the extent the group of physicians submits data on such measures. 

§ 414.1230 Additional measures for groups of physicians. 

 The value-based payment modifier includes the following additional quality 

measures for all groups of physicians: 
CMS-1590-P 753 

 

(a) A composite of rates of potentially preventable hospital admissions for heart failure, 

chronic obstructive pulmonary disease, and diabetes. The rate of potentially preventable 

hospital admissions for diabetes is a composite measure of uncontrolled diabetes, short term 

diabetes complications, long term diabetes complications and lower extremity amputation for 

diabetes. 

(b) A composite rates of potentially preventable hospital admissions for dehydration, 

urinary tract infections, and bacterial pneumonia. 

(c) Rates of an all-cause hospital readmissions measure. 

(d) A 30-day post-discharge visit measure. 

§ 414.1235 Cost measures. 

 Costs for groups of physicians are assessed based on the following five cost measures: 

(a) Total per capita costs for all attributed beneficiaries; and 

(b) Total per capita costs for all attributed beneficiaries with diabetes, coronary artery 

disease, chronic obstructive pulmonary disease, or heart failure. 

(c) Total per capita costs include all payments made under Medicare Part A and Part B. 

(1) Payments under Medicare Part A and Part B will be adjusted using CMS’ payment 

standardization methodology to ensure fair comparisons across geographic areas. 

(2) The CMS-HCC model (and adjustments for ESRD status) is used to adjust 

standardized payments for each cost measure; that is-- 

(i) Total per capita costs; and 

(ii) Total per capita costs for beneficiaries with the following conditions: coronary artery 

disease, COPD, diabetes, and heart failure. 

§ 414.1240 Attribution for quality of care and cost measures. 
CMS-1590-P 754 

 

Beneficiaries are attributed to groups of physicians using the method specified under the 

Physician Quality Reporting System. 

§ 414.1245 Scoring methods for the value-based payment modifier. 

 For each quality of care and cost measure, a standardized score is calculated for each 

group of physicians by dividing-- 

(1) The difference between their performance rate and the benchmark, by 

(2) The measure’s standard deviation. 

§ 414.1250 Benchmarks for quality of care measures. 

 The benchmark for each quality of care measure is the national mean for that measure’s 

performance rate during the performance period. In calculating the national benchmark, groups 

of physicians’ performance rates are weighted by the number of cases used to calculate the 

group of physician’s performance rate. 

§ 414.1255 Benchmarks for cost measures. 

The benchmark for each cost measure is the national mean of the performance rates 

calculated among all groups of physicians for which beneficiaries are attributed to the group of 

physicians. In calculating the national benchmark, groups of physicians’ performance rates are 

weighted by the number of cases used to calculate the group of physician’s performance rate. 

§ 414.1260 Composite scores. 

(a)(1) The standardized score for each quality of care measure is classified into one of 

the following equally weighted domains to determine the quality composite: 

(i) Patient safety. 

(ii) Patient experience. 

(iii) Care coordination. 

(iv) Clinical care. 
CMS-1590-P 755 

 

(v) Population/community health. 

(vi) Efficiency. 

(2) If a domain includes no measure or does not reach the minimum case size in 

§ 414.1265, the remaining domains are equally weighted to form the quality of care composite. 

(b)(1) The standardized score for each cost measure is grouped into two separate and 

equally weighted domains to determine the cost composite: 

(i) Total per capita costs for all attributed beneficiaries (one measures); and 

(ii) Total per capita costs for all attributed beneficiaries with specific conditions: 

diabetes, coronary artery disease, chronic obstructive pulmonary disease, or heart failure (four 

measures). 

(2) Measures within each domain are equally weighted. 

§ 414.1265 Reliability of measures. 

To calculate a composite score for a quality or cost measure based on claims, a group of 

physicians must have 20 or more cases for that measure. 

(a) Where a group of physicians 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. 

(b) Where a reliable quality of care composite or cost composite cannot be calculated, 

payments are not adjusted. 

§ 414.1270 Payment adjustments. 

(a) Downward payment adjustments. For a group of physicians with 25 or more eligible 

professionals that: 

(1) Does not meet the value-based payment modifier satisfactory reporting criteria, 

payments for items and services under the physician fee schedule will be adjusted downward by 

1.0 percent. 
CMS-1590-P 756 

 

(2) Does meet the value-based payment modifier satisfactory reporting criteria, elects 

that their value-based payment modifier be calculated using a quality-tiering approach, and is 

determined to have poor performance (low quality and high costs), payments for items and 

services under the physician fee schedule are adjusted downward by up to 1.0 percent as 

specified in § 414.1275. 

(b) Upward payment adjustments. If a group of physicians with 25 or more eligible 

professionals does meet the value-based payment modifier satisfactory reporting criteria and 

elects that the value-based payment modifier be calculated using a quality-tiering approach, 

upward payment adjustments are determined based on the projected aggregate amount of 

downward payment adjustments determined under subsection (a) above and applied as specified 

in § 414.1275.

§ 414.1275 Payment modifier scoring methodology.. 

(a) The value-based payment modifier amount for a group of physicians that elects the 

quality-tiering approach is based upon a comparison of the composite of quality of care 

measures and a composite of cost measures. 

(b) Groups of physicians’ quality composite and cost composite are classified into high, 

average, and low categories based on whether the composites are statistically above, not 

different from, or below the mean composite scores. 

(c) The following value-based payment modifier amounts apply: 

Value-Based Payment Modifier Amounts for Groups of Physicians Requesting the 

Quality-Tiering Approach 

Quality/cost Low cost Average cost High cost 

High quality +2.0x* +1.0x* +0.0% 

Average quality +1.0x* +0.0% -0.5% 

Low quality +0.0% -0.5% -1.0% 

* Groups of physicians eligible for an additional +1.0x if reporting Physician Quality Reporting 

System quality measures through the GPRO using the web-interface, claims, registries, or EHRs, and 

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

(d) Groups of physicians that have an attributed beneficiary population with an average 
CMS-1590-P 757 

 

risk score in the top 25 percent of the risk scores of beneficiaries nationwide and that 

satisfactorily report data on quality measures through the Physician Quality Reporting System 

GPRO using the web-interface, claims, registries, or EHRs reporting mechanisms, receive a 

greater upward payment adjustment as follows: 

(1) Groups of physicians classified as high quality/low cost receive an upward 

adjustment of +3x (rather than +2x) and 

 (2) Groups of physicians classified as either high quality/average cost or average 

quality/low cost receive an upward adjustment of +2x (rather than +1x). 

§ 414.1280 Limitation of review. 

(a) There shall be no administrative or judicial review under section 1869 of the Act, 

section 1878 of the Act, or otherwise of all of the following: 

(1) The establishment of the value-based payment modifier. 

(2) The evaluation of the quality of care composite, including the establishment of 

appropriate measure of the quality of care. 

(3) The evaluation of costs composite, including establishment of appropriate measures 

of costs. 

(4) The dates of implementation of the value-based payment modifier. 

(5) The specification of the initial performance period and any other performance period. 

(6) The application of the value-based payment modifier. 

(7) The determination of costs. 

§ 414.1285 Inquiry process.

After the dissemination of the annual Physician Feedback reports, a group of physicians may 

contact CMS to inquire about its report and the calculation of the value-based payment modifier. 

PART 415--SERVICES FURNISHED BY PHYSICIANS IN PROVIDERS, 
CMS-1590-P 758 

 

SUPERVISING PHYSICIANS IN TEACHING SETTINGS, AND RESIDENTS IN 

CERTAIN SETTINGS 

22. The authority citation for part 415 continues to read as follows: 

Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 

1395hh). 

§415.130 [Amended] 

23. In §415.130(d)(1) and (d)(2), remove the reference to “December 31, 2011” and add 

in its place the reference to “June 30, 2012.” 

PART 421--MEDICARE CONTRACTING 

24. The authority citation for part 421 continues to read as follows: 

 Authority: Sec. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh). 

Subpart F--[Removed and Reserved] 

25. Subpart F is removed and reserved. 

PART 423--VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT 

26. The authority citation for part 423 continues to read as follows: 

Authority: Sections 1102, 1106, 1860D-1 through 1860D-42, and 1871 of the Social 

Security Act (42 U.S.C. 1302, 1306, 1395w-101 through 1395w-152, and 1395hh). 

27. Section 423.160 is amended by-- 

A. Revising paragraphs (a)(3)(iv), (b)(1)(ii), and (b)(2)(ii) introductory text 

B. Adding paragraphs (b)(1)(iii), (b)(2)(iii), (b)(5)(i), and (b)(5)(ii). 

The revisions and additions read as follows: 

§423.160 Standards for electronic prescribing. 

(a) * * * 

(3) * * * 
CMS-1590-P 759 

 

(iv) Until November 1, 2013, entities transmitting prescriptions or prescription-related 

information where the prescriber is required by law to issue a prescription for a patient to a nonprescribing provider (such as a nursing facility) that in turn forwards the prescription to a 

dispenser are exempt from the requirement to use the NCPDP SCRIPT Standard adopted by this 

section in transmitting such prescriptions or prescription-related information. After January 1, 

2012, entities transmitting prescriptions or prescription-related information where the prescriber 

is required by law to issue a prescription for a patient to a non-prescribing provider (such as a 

nursing facility) that in turn forwards the prescription to a dispenser must utilize the NCPCP 

SCRIPT 

* * * * * 

(b) * * * 

(1) * * * 

(ii) Before November 1, 2013 the standards specified in paragraphs (b)(2)(ii) and (b)(3) 

of this section. 

(iii) On or after November 1, 2013, the standards specified in paragraphs (b)(2)(ii) and 

(b)(3) through (b)(6) of this section. 

(2) * * * 

(ii) The National Council for Prescription Drug Programs SCRIPT standard, 

Implementation Guide Version 10.6, approved November 12, 2008 (incorporated by reference in 

paragraph (c)(1)(v) of this section), or the National Council for Prescription Drug Programs 

Prescriber/Pharmacist Interface SCRIPT Standard, Implementation Guide, Version 8, Release 1 

(Version 8.1), October 2005 (incorporated by reference in paragraph (c)(1)(i) of this section), to 

provide for the communication of a prescription or prescription-related information between 

prescribers and dispensers, for the following: 
CMS-1590-P 760 

 

* * * * * 

(iii) The National Council for Prescription Programs SCRIPT standard, Implementation 

Guide Version 10 release 6 approved November 12, 2008 (incorporated by reference in 

paragraph (c)(1)(i) of this section), to provide for the communication of a prescription or related 

prescription related information between prescribers and dispensers. 

* * * * * 

(5) * * * 

(i)Formulary and benefits. The National Council for Prescription Drug Programs 

Formulary and Benefits Standard, Implementation Guide, Version 1, Release 0 (Version 3.0), 

January 2011(incorporated by reference in paragraph (c)(1)(ii) of this section) for transmitting 

formulary and benefits information between prescribers and Medicare Part D sponsors. 

(ii) Formulary and benefits. The National Council for Prescription Drug Programs 

Formulary and Benefits Standard, Implementation Guide, Version 1, Release 0 (Version 1.0), 

October 2005 (incorporated by reference in paragraph (c)(1)(ii) of this section) for transmitting 

formulary and benefits information between prescribers and Medicare Part D sponsors; or The 

National Council for Prescription Drug Programs Formulary and Benefits Standard, 

Implementation Guide, Version 1, Release 0 (Version 3.0), January 2011(incorporated by 

reference in paragraph (c)(1)(ii) of this section) for transmitting formulary and benefits 

information between prescribers and Medicare Part D sponsors. 

* * * * * 

 28. Subpart F, consisting of §421.500 through §421.505 is removed and reserved. 

PART 425--MEDICARE SHARED SAVINGS PROGRAM 

29. 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 
CMS-1590-P 761 

 

and 1395hh). 

30. Section 425.308 is amended by revising paragraph (e) to read as follows: 

§425.308 Public reporting and transparency. 

* * * * * 

(e) Results of claims based measures. Quality measures reported using the GPRO web 

interface and patient experience of care survey measures will be reported on Physician Compare 

in the same way as for the group practices that report under the Physician Quality Reporting 

System. 

31. Section 425.504 is amended by adding paragraph (b) to read as follows: 

§425.504 Incorporating reporting requirements related to the Physician Quality Reporting 

System. 

* * * * * 

(b) Physician Quality Reporting System payment adjustment. 

(1) ACOs, on behalf of their ACO provider/suppliers who are eligible professionals, must 

submit the measures determined under §425.500 using the GPRO web interface established by 

CMS, to satisfactorily report on behalf of their eligible professionals for purposes of the 

Physician Quality Reporting System payment adjustment under the Shared Savings Program. 

(2)(i) ACO providers/suppliers that are eligible professionals within an ACO may only 

participate under their ACO participant TIN as a group practice under the Physician Quality 

Reporting System Group Practice Reporting Option of the Shared Savings Program for purposes 

of the Physician Quality Reporting System payment adjustment under the Shared Savings 

Program. 

(ii) Under the Shared Savings Program, an ACO, on behalf of its ACO 

providers/suppliers who are eligible professionals, must satisfactorily report the measures 

determined under Subpart F of this part during the reporting period for a year, as defined in 
CMS-1590-P 762 

 

paragraph (b)(6) of this section, according to the method of submission established by CMS 

under the Shared Savings Program for purposes of the Physician Quality Reporting System 

payment adjustment. 

(3) If an ACO, on behalf of its ACO providers/suppliers who are eligible professionals, 

does not satisfactorily report for purposes of a Physician Quality Reporting System payment 

adjustment, each ACO supplier/provider who is an eligible professional, will receive a payment 

adjustment, as described in paragraph (b)(5) of this section. 

(4) ACO participant TINs and individual ACO providers/suppliers who are eligible 

professionals cannot satisfactorily report for purposes of a Physician Quality Reporting System 

payment adjustment outside of the Medicare Shared Savings Program. 

(5) For eligible professionals subject to the Physician Quality Reporting System payment 

adjustment under the Medicare Shared Savings Program, the Medicare Part B Physician Fee 

Schedule amount for covered professional services furnished during the program year is equal to 

the applicable percent of the Medicare Part B Physician Fee Schedule amount that would 

otherwise apply to such services under section 1848 of the Act. 

(i) The applicable percent for 2015 is 98.5 percent. 

(ii) The applicable percent for 2016 and subsequent years is 98.0 percent. 

(6) The reporting period for a year is the calendar year from January 1 through 

December 31 that occurs 2 years prior to the program year in which the payment adjustment is 

applied. 

PART 486--CONDITIONS FOR COVERAGE OF SPECIALIZED SERVICES 

FURNISHED BY SUPPLIERS 

 32. The authority citation for part 486 continues to read as follows: 
CMS-1590-P 763 

 

Authority: Secs. 1102, 1138, and 1871 of the Social Security Act (42 U.S.C. 1302, 

1320b-8, and 1395hh) and section 371 of the Public Health Service Act (42 U.S.C 273). 

33. Section 486.106 is amended by revising the introductory text and paragraphs (a) and 

(b) to read as follows: 

§486.106 Condition for coverage: Referral for service and preservation of records. 

All portable X-ray services performed for Medicare beneficiaries are ordered by a 

physician or a nonphysician practitioner as provided in §410.32(a) of this chapter or by a 

nonphysician practitioner as provided in §410.32(a)(2) and records are properly preserved. 

(a) Standard—referral by a physician or nonphysician practitioners. Portable X-ray 

examinations are performed only on the order of a physician licensed to practice in the State or 

by a nonphysician practitioner acting within the scope of State law. Such nonphysician 

practitioners may be treated the same as physicians treating beneficiaries for the purpose of this 

paragraph. The supplier’s records show that: 

(1) The portable X-ray test was ordered by a licensed physician or a nonphysician 

practitioner acting within the State scope of law; and 

(2) Such physician or nonphysician practitioner’s written, signed order specifies the 

reason a portable X-ray test is required, the area of the body to be exposed, the number of 

radiographs to be obtained, and the views needed; it also includes a statement concerning the 

condition of the patient which indicates why portable X-ray services are necessary. 

(b) Standard—records of examinations performed. The supplier makes for each patient a 

record of the date of the portable X-ray examination, the name of the patient, a description of the 

procedures ordered and performed, the referring physician or nonphysician practitioner, the 

operator(s) of the portable X-ray equipment who performed the examination, the physician to

whom the radiograph was sent, and the date it was sent.
CMS-1590-P 764 

 

* * * * * 

PART 495--STANDARDS FOR THE ELECTRONIC HEALTH RECORD 

TECHNOLOGY INCENTIVE PROGRAM 

34. The authority citation for part 495 continues to read as follows: 

Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 

1395hh). 

35. Section 495.8 is amended by revising paragraph (a)(2)(v) to read as follows: 

§ 495.8 Demonstration of meaningful use criteria. 

(a) * * * 

(2) * * * 

(v) Exception for Medicare EPs for PY 2012 and 2013—Participation in the Physician 

Quality Reporting System-Medicare EHR Incentive Pilot. To satisfy the clinical quality measure 

reporting requirements of meaningful use, aside from attestation, an EP participating in the 

Physician Quality Reporting System may also participate in the Physician Quality Reporting 

System-Medicare EHR Incentive Pilot through one of the following methods: 

(A) Submission of data extracted from the EP’s certified EHR technology through a 

Physician Quality Reporting System qualified EHR data submission vendor; or 

(B) Submission of data extracted from the EP’s certified EHR technology, which must 

also be through a Physician Quality Reporting System qualified EHR. 

* * * * * 
CMS-1590-P 

 

Authority: (Catalog of Federal Domestic Assistance Program No. 93.773, Medicare--

Hospital Insurance; and Program No. 93.774, Medicare--Supplementary Medical Insurance 

Program) 

Dated: June 27, 2012

 ______________________ 

 Marilyn Tavenner, 

 Acting Administrator,

Centers for Medicare & 

Medicaid Services 

Approved: June 28, 2012

 _____________________ 

 Kathleen Sebelius, 

 Secretary.

BILLING CODE 4120-01-P 

[FR Doc. 2012-16814 Filed 07/06/2012 at 4:15 pm; Publication Date: 07/30/2012]