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The Physician Quality Reporting System measures quality based onfour factors:

Eligibility for a measure.1.Performance in meeting the measure.2.Reporting rate3.Performance rate.4.

Eligibility

Each measure has a set of criteria to determine if the patient data iseligible for the particular measure.

The critieria are generally specific to:

Time frame (in the last year, two years etc)Age rangeProcedure (CPT) codeDiagnosis (ICD-9) codePlace of serviceOther disease-specific factors.

Usually, the eligibilty data can be determined from the PracticeManagement System. There are some measures where the eligibilitycannot be determined without reviewing the patient record.

The number of patients eligible becomes the denominator (D) of thePQRS Quality Equation.

Performance

Perfomance is the number of eligible patients who meet theperformance criteria or for whom the quality action was performed.

The performance is described as

Met: Performance criteria met or quality action performed.Not Met: Performance criteria not met or quality action notperformed.Excluded: There is a medical, patient or system reason documentedin the patient record for not meeting the perfomance criteria (not allmeasures allow exclusions)

The determination of Met, Not Met or Excluded, must come from areview of the patient record, either paper or electronic.

Reporting Rate (RR)

The Reporting Rate is the number of patients reported (PerformanceMet (A) + Performance Not Met (B) + Performance Exclusions(C))divided by the total number of Eligible Patients (D) expressed inpercent.

RR=(A + B+ C)/D*100

In order to qualify for an incentive payment, you must have aReporting Rate of 80% or above.

Peformance Rate (PR)

The number of patients who meet the performance criteria (or forwhom the quality action was performed) (A) divided by the number ofpatients.reported (E) minus the number excluded (C).

PR=A/(E-C)

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Example

Measure 6: Coronary Artery Disease (CAD) Antiplatelet Therapy

Patient data that is eligible for this measure includes all patients inyour practice who are age 18 or older with a diagnosis of CAD(410.00, 410.01, 410.02 etc) and a CPT code of 99201, 99202,99203 etc.

The performance criteria is the number of eligible patients who wereprescribed aspirin or clopidogrel.

Patients who could not be prescribed aspirin or clopidogrel formedical, patient or system reasons (e.g. allergy, patient declined orlack of drug availability) are excluded from the measure.

Assumptions:

There are 75 patients in your practice who meet eligibilty criteria.D=75

67 of the eligible patients were given aspirin.(A=67)

2 were not given aspirin or clopidogrel and there was nodocumentation as to why. (B=2)

5 of the 75 patients are allergic to aspirin and clopidogrel.(C=5)

1 patient chart could not be found.

RR=(67+2+5)/75*100=98.66%PR=67/(74-5)*100=97.10%

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