Projects: N²QOD
Physician Quality Reporting System

The National Neurosurgery Quality & Outcomes Database (N2QOD) has been approved as a Qualified Clinical Data Registry (QCDR) for the Medicare Physician Quality Reporting System (PQRS) 2016 reporting year. N2QOD now offers two separate QCDRs for reporting: one for surgical spine and one for general spine care.

The N2QOD QCDR reporting mechanisms provide participating registry eligible professionals (EPs) with a method to satisfy PQRS requirements and avoid associated penalties by reporting on a more meaningful set of non-PQRS measures developed by the profession. The N2QOD can serve as a tool to assist EPs with meeting the following QCDR reporting requirements:

  1. Report at least nine measures covering three National Quality Strategy (NQS) domains for at least 50 percent of the EPs applicable patients seen during the 2016 participation period.
  2. Report on at least two outcome measures.

The N2QOD Surgical Spine QCDR offers twenty-one unique, surgical spine non-PQRS measures that have been approved by the Centers for Medicare & Medicaid Services (CMS) and from which an EP can choose to report for purposes of satisfying the PQRS. These measures, focused on surgical spine care, are the first specialty-specific measures developed by the profession for purposes of satisfying federal quality reporting mandates. The list of Surgical Spine Care measures available through the N2QOD for 2016 PQRS reporting are listed below:

N2QOD Surgical Spine Non-PQRS Measures:

NPA 1

Spine Pain Assessment

NPA 2

Extremity (Radicular) Pain Assessment

NPA 3

Functional Outcome Assessment for Spine Intervention

NPA 4

Quality of Life Assessment for Spine Intervention

NPA 5

Patient Satisfaction with Spine Care

NPA 6

Spine‐related procedure Site Infection

NPA 7

Complication Following Spine‐related Procedure

NPA 8

Hospital Mortality following Spine Procedure

NPA 9

Referral for post‐acute Care Rehabilitation

NPA 10

Unplanned Reoperation Following Spine Procedure Within the 30-day Post‐Operative Period

NPA 11

Unplanned Readmission Following Spine Procedure Within the 30-day Post‐Operative Period

NPA 12

Selection of Prophylactic Antibiotic - First or Second Generation Cephalosporin - Prior to Spine Procedure

NPA 13

Discontinuation of Prophylactic Parenteral Antibiotics Following Spine Procedure

NPA 14

Medicine Reconciliation Following Spine Related Procedure

NPA 15

Risk–assessment for Elective Spine Procedure

NPA 16

Depression and Anxiety Assessment Prior to Spine‐Related Therapies

NPA 17

Narcotic Pain Medicine Management Following Elective Spine Procedure

NPA 18

Smoking Assessment and Cessation Coincident with Spine-related Therapies

NPA 19

Body Mass Assessment and Follow‐up Coincident with Spine-related Therapies

NPA 20

Unhealthy Alcohol Use Assessment Coincident With Spine Care

NPA 21

Participation in a Systematic National Database for Spine Care Interventions

The complete list of surgical spine measures and specifications can be found here: N2QOD Surgical Spine Non-PQRS Measure Specification.

The N2QOD General Spine Care QCDR offers nine unique, general spine non-PQRS measures focused on non-surgical spine therapy that have been approved by the CMS.  The General Spine Care QCDR provides spine care practitioners with a complete method for satisfying PQRS requirements. The list of General Spine Care measures available through the N2QOD for 2016 PQRS reporting are listed below:

NPAGSC 1

Spine Pain Assessment

NPAGSC 2

Extremity (Radicular) Pain Assessment

NPAGSC 3

Functional Outcome Assessment for Spine Intervention

NPAGSC 4

Quality-of-life Assessment for Spine Intervention

NPAGSC 5

Patient Satisfaction with Spine Care

NPAGSC 6

Depression and Anxiety Assessment Prior to Spine-related Therapies

NPAGSC 7

Narcotic Pain Medicine Management Prior to and Following Spine Therapy

NPAGSC 8

Complication Following Percutaneous Spine-related Procedure

NPAGSC 9

Unplanned Admission to Hospital Following Percutaneous Spine Procedure within the 30-day Post-procedure Period

The complete list of general spine care measures and specifications can be found here: N2QOD General Spine Care Non-PQRS Measure Specification.

The N2QOD QCDR is open to all participating N2QOD registry physicians. EPs interested in participating in the N2QOD QCDR who are not currently participating in the N2QOD registry can enroll by completing the steps for N2QOD participation at: http://www.neuropoint.org/NPA%20N2QOD%20Participation.html.

The PQRS is a Medicare reporting program under which physicians are required to report quality measures data to CMS.  In 2016, EPs who do not satisfactorily participate in PQRS will be subject to a 2.0% cut in their 2018 Medicare payments.  PQRS reporting also has implications for other penalty-driven federal programs, such as the Physician Value-Based Payment Modifier (VM). To learn more about the various PQRS reporting options available to neurosurgeons, as well as other programs such as the VM, visit: http://www.aans.org/pdf/Legislative/PQRS%202015%20%20What%20Neurosurgeons%20Need%20to%20Know.pdf.

Additional information about PQRS reporting via a QCDR is available here: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/How_To_Get_Started.html.

Please contact the NPA at info@neuropoint.org, tel: 847-378-0549, with questions or for more information on the N2QOD and N2QOD QCDR.