2016 Physician Quality Reporting System Data Collection Form: General Surgery (for
patients aged 18 and older)
IMPORTANT: Any measure with a 0% performance rate (100% for inverse measures) is not
considered satisfactory reporting. Review your PQRS Submission Summary report, available after
entering your data, to ensure this is not an issue. Each measure answer is identified as Performance Met (PM),
Performance Not Met (PNM) or Performance Exclusion (PE). More information on this rule is available within the
Covisint PQRS Web Application.
Note: This measures group contains one or more inverse measures. An inverse measure is a measure that represents a poor
clinical quality action as meeting performance for the measure. For these measures, a lower performance rate indicates a
higher quality of clinical care. Composite codes for measures groups that contain inverse measures are only utilized when the
appropriate quality clinical care is given.
Patient sample criteria for the General Surgery Measures Group are: patients aged 18 years and older with
specific surgical procedures performed:
The general surgery measures group is relevant to the following surgical procedures: Ventral Hernia,
Appendectomy, AV Fistula, Cholecystectomy, Thyroidectomy, Mastectomy +/- Lymphadenectomy or Sentinel Lymph Node
Biopsy (SLNB), Partial Mastectomy or Breast Biopsy/Lumpectomy +/- Lymphadenectomy or SLNB, Bariatric Laparoscopic
or Open Roux en Y Gastric Bypass, Bariatric Sleeve Gastrectomy, Colectomy



One of the following procedure codes indicating general surgery: 19101, 19301, 19302, 19303, 19304,
19305, 19306, 19307, 36818, 36819, 36820, 36821, 36825, 36830, 43644, 43645, 43775, 43846, 43847, 44140,
44141, 44143, 44144, 44145, 44146, 44147, 44150, 44151, 44160, 44204, 44205, 44206, 44207, 44208, 44210, 44950,
44960, 44970, 47562, 47563, 47564, 47600, 47605, 47610, 49560, 49561, 49565, 49566, 49572, 49585, 49587,
49590, 49652, 49653, 49654, 49655, 49656, 49657, 60200, 60210, 60212, 60220, 60225, 60240, 60252, 60254,
60260, 60270, 60271
Measure #354 need only be reported when the patient has a procedure performed specific to gastric bypass
surgery or colectomy as indicated by the following CPT procedure codes: 43644, 43645, 43846, 43847, 43775, 44140,
44141, 44143, 44144, 44145, 44146, 44147, 44150, 44151, 44160, 44204, 44205, 44206, 44207, 44208, 44210
Measure #358 does not need to be reported (is not applicable) when the patient has a procedure performed for one
of the following AV Fistula CPT procedure codes: 36820, 36821, 36825. These codes are not available through a
clinical data-based, patient-specific risk calculator.
PLEASE REFER TO THE “GENERAL SURGERY” MEASURES GROUP IN THE CMS 2016 PQRS MEASURES GROUPS
SPECIFICATIONS MANUAL FOR CLINICAL RECOMMENDATIONS AND FURTHER INFORMATION.
Page 2 of 7
Physician Name: _____________________________
Patient Name: ______________________________
Last
Gender:
First
MI
Date of Birth:
_____ /_____ /_____
mm
dd
yyyy
Practice Medical Record Number:
□ M □F
_______________________________
Patient Insured Traditional Medicare*:
Medicare Advantage:
Other:
Appointment Date: _____ /____ /_____
□
□
(1/1/16 – 12/31/16)
mm
dd
yyyy
ICD-10) Diagnosis Code: ____N/A_____
□
CPT Encounter (visit) Code: __N/A __
*Note: A minimum of 11 patients must be Traditional Medicare Part B
CPT Procedure Code: ____________
Successful CMS 2016 Physician Quality Reporting General Surgery Measures Group submission requires information from 20
unique patients who have had a General Surgery procedure, the majority of whom must be Medicare Part B FFS.
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Physician Quality Reporting Measure # 130 :
Documentation of Current Medications in the
Medical Record
Percentage of visits for patients aged 18 years and older
for which the eligible professional attests to documenting
a list of current medications using all immediate resources
available on the date of the encounter.
Eligible professional attests to documenting, updating or
reviewing a patient’s current medications using all
immediate resources available on the date of encounter.
This list must include ALL known prescriptions, over-the
counters, herbals, and vitamin/mineral/dietary
(nutritional) supplements AND must contain the
medications’ name, dosages, frequency and route of
administration
Not Eligible - A patient is not eligible if the following
reason is documented:
 Patient is in an urgent or emergent medical
situation where time is of the essence and to delay
treatment would jeopardize the patient’s health
status.
Check One
Eligible professional attests to
documenting in the medical record
they obtained, updated, or reviewed
the patient’s current medications - PM
Eligible professional attests to
documenting in the medical record
the patient is not eligible for a current
list of medications being obtained,
updated, or reviewed by the eligible
professional - PE
Current list of medications not
documented as obtained, updated, or
reviewed by the eligible professional,
reason not given - PNM
For definitions and further information refer to the
measures groups specifications manual
Successful CMS 2016 Physician Quality Reporting General Surgery Measures Group submission requires information from 20
unique patients who have had a General Surgery procedure, the majority of whom must be Medicare Part B FFS.
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Physician Quality Reporting Measure # 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
Note: In the event that a patient is screened for tobacco use
and identified as a user but did not receive tobacco cessation
counseling, choose answer option “tobacco screening OR
tobacco cessation intervention not performed, reason not
otherwise specified”.
Tobacco Use includes any type of tobacco.
Cessation Counseling Intervention includes brief
counseling (3 minutes or less) and/or pharmacotherapy.
Check One
Patient screened for tobacco use
AND received tobacco cessation
intervention (counseling,
pharmacotherapy, or both), if
identified as a tobacco user - PM
Current tobacco non-user - PM
Documentation of medical
reason(s) for not screening for
tobacco use (e.g., limited life
expectancy, other medical reasons)
- PE
Tobacco screening OR tobacco
cessation intervention not
performed, reason not otherwise
specified - PNM
Successful CMS 2016 Physician Quality Reporting General Surgery Measures Group submission requires information from 20
unique patients who have had a General Surgery procedure, the majority of whom must be Medicare Part B FFS.
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Physician Quality Reporting Measure # 354:
Check One
Anastomotic Leak Intervention
Percentage of patients aged 18 years and older who required
an anastomotic leak intervention following gastric bypass or
colectomy surgery
Intervention (via return to operating room, interventional
radiology, or interventional gastroenterology) for presence of
leak of endoluminal contents (such as air, fluid, GI contents, or
contrast material) through an anastomosis. The presence of an
infection/abscess thought to be related to an anastomosis, even
if the leak cannot be definitively identified as visualized during
an operation, or by contrast extravasation would also be
considered an anastomotic leak
This is an INVERSE MEASURE: A lower calculated
performance (PNM) rate for this measure indicates
better clinical care or control.
Intervention for presence of leak of
endoluminal contents through an
anastomosis required - PM
Intervention for presence of leak of
endoluminal contents through an
anastomosis not required - PNM
Patient procedure not specific to gastric
bypass surgery or colectomy, not eligible
Measure #354 need only be reported when the patient has a
procedure performed specific to gastric bypass surgery or
colectomy as indicated by the following CPT procedure codes:
43644, 43645, 43846, 43847, 43775, 44140, 44141, 44143,
44144, 44145, 44146, 44147, 44150, 44151, 44160, 44204,
44205, 44206, 44207, 44208, 44210
Successful CMS 2016 Physician Quality Reporting General Surgery Measures Group submission requires information from 20
unique patients who have had a General Surgery procedure, the majority of whom must be Medicare Part B FFS.
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Physician Quality Reporting Measure # 355 :
Unplanned Reoperation within the 30 Day
Postoperative Period
Percentage of patients aged 18 years and older who had any
unplanned reoperation within the 30 day postoperative period
This measure is not intended to capture patients who go back to
the operating room within 30 days for a follow-up procedure
based on the pathology results from the principal operative
procedure or concurrent procedure.
Examples: exclude breast biopsies with return for re-excisions;
insertion of port-a-cath for chemotherapy.
Check One
Unplanned return to the operating room for a
surgical procedure, for any reason, within 30
days of the principal operative procedure PM
No return to the operating room for a
surgical procedure, for any reason, within 30
days of the principal operative procedure PNM
The return to the OR may occur at any hospital or surgical
facility.
This is an INVERSE MEASURE: A lower calculated
performance (PNM) rate for this measure indicates
better clinical care or control.
Physician Quality Reporting Measure # 356 :
Unplanned Hospital Readmission within 30 Days
of Principal Procedure
Percentage of patients aged 18 years and older who had an
unplanned hospital readmission within 30 days of principal
procedure
This includes readmission, for any reason, to the same hospital
or outside hospital (if known by the surgeon) within 30 days of
the principal surgical procedure.
Check One
Unplanned hospital readmission within 30
days of principal procedure - PM
No unplanned hospital readmission within
30 days of principal procedure - PNM
This is an INVERSE MEASURE: A lower calculated
performance (PNM) rate for this measure indicates
better clinical care or control.
Successful CMS 2016 Physician Quality Reporting General Surgery Measures Group submission requires information from 20
unique patients who have had a General Surgery procedure, the majority of whom must be Medicare Part B FFS.
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© 2016 Covisint Corporation
Page 7 of 7
Physician Quality Reporting Measure # 357 :
Check One
Surgical Site Infection (SSI)
Percentage of patients aged 18 years and older who had a
surgical site infection (SSI)
This is an INVERSE MEASURE: A lower calculated
performance (PNM) rate for this measure indicates
better clinical care or control.
Surgical site infection - PM
No surgical site infection - PNM
Refer to 2016 CMS PQRS General Surgery measures
group specifications for important definitions related to
this measure.
Physician Quality Reporting Measure # 358 :
Patient-Centered Surgical Risk Assessment and
Communication
Percentage of patients who underwent a non-emergency
surgery who had their personalized risks of
postoperative complications assessed by their surgical
team prior to surgery using a clinical data-based,
patient-specific risk calculator and who received
personal discussion of those risks with the surgeon
This includes documentation of empirical, personalized risk
assessment based on the patient’s risk factors with a validated
risk calculator using multi-institutional clinical data, the
specific risk calculator used, and communication of risk
assessment from risk calculator with the patient and/or family
Refer to 2016 CMS PQRS General Surgery measures
group specifications for important definitions related to
this measure.
Check One
Documentation of patient-specific risk
assessment with a risk calculator based on
multi-institutional clinical data, the specific
risk calculator used, and communication of
risk assessment from risk calculator with
the patient or family - PM
Documentation of patient-specific risk
assessment with a risk calculator based on
multi-institutional clinical data, the specific
risk calculator used, and communication of
risk assessment from risk calculator with
the patient or family not completed - PNM
Procedure performed for one of the
following AV Fistula CPT procedure codes:
36820, 36821, 36825 - measure not
applicable
Successful CMS 2016 Physician Quality Reporting General Surgery Measures Group submission requires information from 20
unique patients who have had a General Surgery procedure, the majority of whom must be Medicare Part B FFS.
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© 2016 Covisint Corporation