2016 Physician Quality Reporting System (PQRS) (Claims-Based Option)


The Physician Quality Reporting System (PQRS) is a voluntary quality reporting program that applies a negative payment adjustment to promote the reporting of quality information by eligible professionals (EPs). The program applies a negative payment adjustment to practices with EPs identified on claims by their individual National Provider Identifier (NPI) and Tax Identification Number (TIN) who do not satisfactorily report data on quality measures for covered Medicare Physician Fee Schedule (MPFS) services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries (including Railroad Retirement Board and Medicare Secondary Payer).

Beginning in 2015, the program applies a negative payment adjustment to EPs who did not satisfactorily report data on quality measures for covered professional services in 2013. Those who report satisfactorily for the 2016 program year will avoid the 2019 PQRS negative payment adjustment.

PQRS gives participating EPs the opportunity to assess the quality of care they are providing to their patients, helping to ensure that patients get the right care at the right time. By reporting PQRS quality measures, providers also can quantify how often they are meeting a particular quality metric.

The types of measures reported under PQRS change from year to year. The measures generally vary by specialty, and focus on areas such as care coordination, patient safety and engagement, clinical process/effectiveness, and population/public health. They can also vary by reporting method.

Physician Quality Reporting System

New In 2016

In order for eligible professionals (EPs) to satisfactorily report Physician Quality Reporting System (PQRS) measures, a new reporting criterion has been added for the claims and registry reporting of individual measures. Eligible professionals are required to report one (1) cross-cutting measure if they have at least one (1) Medicare patient with a face-to-face encounter. The Centers for Medicare & Medicaid Services (CMS) defines a face-to-face encounter as an instance in which the EP billed for services that are associated with face-to-face encounters under the Physician Fee Schedule (PFS). This includes general office visits, outpatient visits, and surgical procedure codes; however, CMS does not consider telehealth visits as a face-to-face encounter.

How to select measures:

At a minimum, the following factors should be considered when selecting measures for reporting:

  • Clinical conditions usually treated
  • Types of care typically provided – e.g., preventive, chronic, acute
  • Settings where care is usually delivered – e.g., office, emergency department (ED), surgical suite
  • Quality improvement goals for 2016
  • Other quality reporting programs in use or being considered

NQS Domains

The six NQS (National Quality Strategy) Domains associated with the PQRS quality measures are as follows:

  • Patient Safety
  • Person and Caregiver-Centered Experience and Outcomes
  • Communication and Care Coordination
  • Effective Clinical Care
  • Community/Population Health
  • Efficiency and Cost Reduction

Reporting Criteria

EPs may satisfactorily report in 2016 PQRS by meeting the following criteria:

  • Report on at least 9 measures across 3 NQS domains for at least 50% of the EP’s Medicare Part B FFS patients.
  • EPs who see 1 Medicare patient in a face-to-face encounter must also report on 1 cross-cutting measure.
  • EPs who submit quality data for only 1 to 8 PQRS measures for at least 50% of their patients or encounters eligible for each measure, OR that submit data for 9 or more PQRS measures across less than 3 domains for at least 50% of their patients or encounters eligible for each measure will be subject to Measure-Applicability Validation (MAV).
  • EPs who see 1 Medicare patient (face-to-face encounter), but do not report on 1 cross-cutting measure will be subject to MAV.
  • Note: Measures with a 0% performance rate will not be counted for either of the options.

Additional Information

For more information on reporting individual measures via claims, please see the resources available on the PQRS Measures Codes webpage.

The 2016 PQRS Individual Measure Specifications for Claims and Registry Reporting can be viewed on the web-based tool. This is a measures list tool that eligible professionals (EPs) can use to search for measures to report for the 2016 PQRS Program. The web-based measures list tool allows users to search for measures using a number of criteria and then access detailed information about each measure, including measure specifications materials.

For more information related to the 2016 PQRS payment adjustment, please refer to the PQRS webpage on the CMS website.

For more information on what's new for 2016 PQRS, visit the PQRS Educational Resources webpage.

To find answers to frequently asked questions, visit the CMS FAQ webpage.


Contact the MTBC Meaningful Use Team at (732) 873-5133 ext. 308 or via email at