applicable for routine professional services. They
should select the measures based upon prevalence and
volume in their practice.
The ACS encourages individual surgeons to report
General Surgery Measures Group data. This requires
reporting on a minimum of 20 patients, at least 11 of
whom should be Medicare Part B beneficiaries. Surgeons who choose this option must report on all seven
measures listed in Table 3, page 29.
ACS resources for PQRS reporting
The ACS has two registries that can be used for
PQRS reporting. The ACS Surgeon Specific Registry
(SSR) can be used to comply with regulatory requirements, including participation in PQRS. The SSR was
approved by CMS as a registry for 2015 PQRS, and is
pending approval for 2016.
The SSR allows individual surgeons to report on
• The PQRS General Surgery Measures Group
•2016 PQRS individual measures
•2016 SSR QCDR: Trauma Measures Option
Surgeons will have until January 31, 2017, to
submit CY 2016 patient information in the SSR,
which will then submit the PQRS data to CMS.
CMS also has approved the Metabolic and Bariatric Surgery Accreditation and Quality Improvement
Program (MBSAQIP) as a QCDR for PQRS 2015;
approval for 2016 was pending at press time.
MBSAQIP participants will have the opportunity
to voluntarily elect that their MBSAQIP QCDR
satisfactory participation criteria
2–99 EPs; 100+ EPs
(if CAHPS for PQRS
does not apply)
product or EHR
Report 9 measures covering at least 3 domains.
If the group practice’s direct EHR product or EHR
data submission vendor product does not contain
patient data for at least 9 measures covering at least
3 domains, then the group practice must report all
of the measures for which Medicare patient data are
available. A group practice must report on at least
1 measure that includes Medicare patient data.
2–99 EPs that elect
CAHPS for PQRS;
100+ EPs (if CAHPS
for PQRS applies)
CAHPS for PQRS
product or EHR
The group practice must have all CAHPS for PQRS
survey measures reported on its behalf via a CMS-
certified survey vendor and report at least 6 additional
measures, outside of CAHPS for PQRS, covering at least
2 of the NQS domains using the direct EHR product
or EHR data submission vendor product. If fewer
than 6 measures apply to the group practice, it must
report all of the measures for which Medicare patient
data are available. Of the additional 6 measures that
must be reported in conjunction with reporting the
CAHPS for PQRS survey measures, a group practice
would be required to report on at least 1 measure
for which Medicare patient data are available.
Report at least 9 measures available for reporting under
a QCDR covering at least 3 NQS domains and report
each measure for at least 50 percent of the group
practice’s patients. Of these measures, the group practice
would report on at least two outcome measures or, if
2 outcomes measures are not available, report on at
least 1 outcomes measure and at least 1 of the following
types of measures—resource use, patient experience
of care, efficiency/appropriate use, or patient safety.
Note: Group practice reporting criteria for satisfactory reporting of quality measures data via the GPRO.
TABLE 2. (CONTINUED)
GROUP PRACTICE REPORTING REQUIREMENTS FOR 2018 PQRS PAYMENT ADJUSTMENT
V101 No 5 BULLETIN American College of Surgeons