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Centers for Medicare & Medicaid Services CMS eXpedited Life Cycle (XLC)

Physician Quality Reporting System (PQRS) Program Year 2016

Submission Engine Validation Tool (SEVT) User Manual

Version: 1.0 10/06/2016

Document Number: N/A Contract Number: HHSM-500-2007-00017I, Task Order HHSM-500-TO002

CMS XLC Table of Contents

PQRS Submission Engine Validation Tool (SEVT) User Manual V 1.0 i Program Year 2016

Table of Contents

Disclaimer ...................................................................................................................... 1

1. Introduction .............................................................................................................. 2

2. Overview ................................................................................................................... 2

2.1 Conventions ..................................................................................................... 3

2.2 Cautions & Warnings ........................................................................................ 4

3. Getting Started ......................................................................................................... 4

3.1 Set-Up Considerations ..................................................................................... 4

3.1.1 Hardware Requirements ................................................................................... 4

3.1.2 Software Requirements .................................................................................... 5

3.1.3 Internet Connection Requirements ................................................................... 5

3.2 User Access Considerations ............................................................................ 5

3.3 Accessing the System ...................................................................................... 5

3.4 Organization Selection ................................................................................... 10

3.5 System Organization & Navigation ................................................................. 11

3.6 Exiting the System .......................................................................................... 12

4. Using the System ................................................................................................... 13

4.1 Submitting an XML File for Validation ............................................................. 13

4.2 File Validation Passed .................................................................................... 14

4.3 File Validation Failed ...................................................................................... 15

4.4 Submitting a ZIP File for Validation ................................................................ 17

4.5 Program Year 2016 Specifications ................................................................. 18

4.6 Batch Validation Results ................................................................................. 19

5. Troubleshooting & Support .................................................................................. 20

5.1 Troubleshooting Tips ...................................................................................... 20

5.2 Errors Generated in User Interface (UI) Screen ............................................. 21

5.2.1 PQRS Error Messages ................................................................................... 22

5.2.2 System Generated Error Messages ............................................................... 46

5.3 Special Considerations ................................................................................... 46

CMS XLC Table of Contents

PQRS Submission Engine Validation Tool (SEVT) User Manual V 1.0 ii Program Year 2016

5.4 Support ........................................................................................................... 46

Acronyms ..................................................................................................................... 47

Glossary ....................................................................................................................... 49

Referenced Documents .............................................................................................. 51

Record of Changes ..................................................................................................... 52

CMS XLC Disclaimer

PQRS Submission Engine Validation Tool (SEVT) User Manual V 1.0 1 Program Year 2016

Disclaimer This information was current at the time it was published or uploaded onto the web. Medicare policy changes frequently, so links to source documents have been provided within the document for reference.

This document was prepared as a tool to help Eligible Professionals (EPs) and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide. This publication is a general summary that explains certain aspects of the Medicare program, but is not a legal document. The official Medicare program provisions are contained in the relevant laws, regulations, and rulings.

CMS XLC Introduction


1. Introduction This user manual provides the information necessary to effectively use the Submission Engine Validation Tool (SEVT) to validate the format of data files. The files are validated against the most current published data submission specifications.

Beginning in September 2016, the SEVT Application transitioned to the QualityNet Secure Portal (QSP) solution which is available via the QSP.

The SEVT provides registered users with an interface on the current QSP to submit and authenticate the Extensible Markup Language (XML) file based on the following formats:

• Registry XML Specifications

• Qualified Clinical Data Registries (QCDR) XML Specifications

• Quality Reporting Data Architecture (QRDA) Specification

• Health Level 7 (HL7) Implementation Guide for CDA Release 2: Quality Reporting Document Architecture (QRDA) Category I, Release 1, Draft Standard for Trial Use (DSTU) Release 3, US Realm, June 2015

• HL7 Implementation Guide for CDA Release 2: QRDA, Category III, DSTU Release 1, November 2012 and its July 2014 errata update for the 2016 reporting year.

• QRDA CMS IG Specification Document

The stakeholders and audience for this user manual consist of the following:

• Centers for Medicare & Medicaid Services (CMS)

• Eligible Professionals (EPs)

• Electronic Health Record (EHR) Vendors

• Registries

• Qualified Clinical Data Registries (QCDRs)

• Data Submission Vendors (DSVs)

This PDF is provided as a reference only. It is NOT 508 compliant. For a 508 compliant version of this content, please refer back to the web-based content.

2. Overview Physician Quality Reporting System (PQRS) is a voluntary reporting program for EPs and group practices to report information on the quality of care to Medicare who satisfactorily report data on quality measures for covered Physician Fee Schedule (PFS) services furnished to Medicare

CMS XLC Overview


Part B beneficiaries in accordance with Section 101 of Division B of the Tax Relief and Health Care Act of 2006 (Pub. Law 109-432) (TRHCA). PQRS was further extended and enhanced by legislation such as the Medicare, Medicaid, and SCHIP Act of 2007 (Pub. Law 110-173) (MMSEA), and the Medicare Improvements for Patients and Providers Act of 2008 (Pub. Law 110-275) (MIPPA). The SEVT has been created to allow EPs and group practices to validate the data structure of the submitted data files within the current infrastructure of the QSP.

2.1 Conventions

This document provides screen prints and corresponding narrative to describe how to use the SEVT. The document uses the following conventions:

• Fields or buttons to be acted upon are indicated in bold; links to be acted upon are indicated as links in underlined blue text.

• The term “User” refers to a person who requires and/or has acquired access to the SEVT.

Throughout the system, fields in which an entry is required are marked with a red asterisk (*).

This document is an Adobe® Acrobat® PDF. You may use the table of contents to “jump” to sections in the document. You may also use Adobe’s built-in search functionality to search by keyword. To perform a search:

From the toolbar, select Edit | Find (keyboard shortcut: CTRL+F).

In the upper right of the window, enter your keyword.

Click the right arrow to move forward through each instance of the keyword; click the left arrow to view previous instances within the document.

CMS XLC Getting Started


2.2 Cautions & Warnings

Files submitted for validation cannot contain personal health information (PHI) or personally identifiable information (PII).

To view the error reports described in this manual, either turn off the web browser’s pop-up blocker or temporarily allow pop-up files.

3. Getting Started In this topic, you will learn about:

Set-Up Considerations

Hardware Requirements

Software Requirements

Internet Connection Requirements

User Access Considerations

Accessing the System

System Organization & Navigation

Exiting the System

3.1 Set-Up Considerations

The minimum system requirements to effectively access the QSP are listed in the following subsections.

3.1.1 Hardware Requirements

• Computer with a 1 gigahertz (GHz) processor with minimum of 150 MB of free disk space



• Windows-7 with 512 MB memory

3.1.2 Software Requirements

• Microsoft Internet Explorer version 11.0

• Windows 7 operating system

• Adobe Reader Version 5.0, https://www.adobe.com

• Microsoft Office Excel 2007, https://www.microsoft.com

3.1.3 Internet Connection Requirements

The SEVT will be accessible via any Internet connection running on a minimum 33.6k or high-speed connection.

CMS screens are designed to be viewed at a minimum screen resolution of 800 x 600. To optimize access to the SEVT:

1. Disable pop-up blockers prior to attempting access to the SEVT

2. Use Internet Explorer Version 11.0

3.2 User Access Considerations

To sign in to the SEVT, the user must have a CMS Identity Management System (EIDM) account. Users with the following roles can test their submission using SEVT:

• PQRS Submitter (Organization)

• Individual Practitioner

• Individual Practitioner Representative

3.3 Accessing the System

The SEVT Portal is available throughout the calendar year and will be accessible through the QSP.

1. From the web browser, go to: https://www.qualitynet.org/pqrs to access the QSP.

2. The Home Page of the PQRS Portal appears,click the Sign In button.

https://www.adobe.com/

https://www.microsoft.com/

https://www.qualitynet.org/pqrs



3. Terms and Conditions form of the CMS Enterprise Portal appears. Read the text, and then click the I Accept button.



4. Enter your identifier in the User ID field and select the Next button to continue signing in with the Multi-Factor Authentication (MFA) process.



5. The second Sign in form is displayed. This form includes the Password, MFA Device Type drop down box and the Security Code.

6. Enter your password in the Password textbox.

7. Select your MFA Device Type option in the MFA Device Type drop-down menu and click the Send button which is displayed next to the select MFA Device Type box to receive a one-time security code.



Note: The Send action button is only displayed for selected MFA Device Type options in accordance with your MFA access settings. If you did not register for MFA access, click on the Register MFA Device hyperlink located at the bottom of the form.

8. Type in the security code that is delivered to you via the e-mail or mobile phone (text message) or displayed on your secure connection device in the Security Code field.

9. Click on the Log-in button to complete the sign in process.

10. The QSP Landing page appears after successfully completing the QSP login process.

To access the PQRS applications/portlets:

11. Select the Physician Quality Reporting System option in the Quality Program menu.



3.4 Organization Selection

When accessing the PQRS applications on the QSP for the first time, the user is automatically assigned as a single user’s organization (i.e. assigned as default organization by the system). User will be able to switch between organizations without logging out of the QSP. The last used organization during a single login session will be set as the default organization used for the next login session.

1. Click on the arrow next to the User Profile menu on the top right-bar and select the User Accessibility menu option.



2. The User Accessibility form opens. Select the Organization Switch tab on the form and proceed with the organization change.

3. To change the user’s organization, select Physician Quality Reporting System option from the Change Program drop-down menu, then select the organization type from the list of displayed organizations in the Change Organization drop-down.

4. Click the Update button.

3.5 System Organization & Navigation

After logging into the QSP, the Quality Reporting System: My Tasks page appears.

1. Click the Submission Engine Validation Tool hyperlink found within the Submission Services section.



3.6 Exiting the System

To log off the Portal, from the site navigation menu on the top right-hand corner of the screen:

1. Click the Log Out button.

A pop-up box appears containing the message Log Out Confirmation Do you want to log out?

2. Click the Yes button to log out.

CMS XLC Using the System


4. Using the System The following sub-sections provide detailed, step-by-step instructions on how to use the various functions or features of the SEVT:

Submitting an XML File for Validation

File Validation Passed

File Validation Failed

Submitting a ZIP File for Validation

Program Year 2016 Specifications

Batch Validation Results

4.1 Submitting an XML File for Validation

To submit an XML file for validation:

1. On the SEVT home page, in the Participation Year field, the default option selected is 2016.

2. To upload a file, click the Browse button to attach the XML file. The uploaded XML file should not exceed 20 MB in size.

3. Click the Validate button to process the file.



4. To clear the selected file field, click the Reset button.

4.2 File Validation Passed

If the submitted file passes validation, a pop-up box appears containing the file name and message “File Validation Passed. No Error(s) and Warning(s).”

1. To validate another file, click the OK button.

2. If the submitted file passes validation with warning(s), a pop-up box appears containing the file name and message: “The file passed validation with (#) Warnings(s).”

3. To view the warning(s) report, click on the hyperlink. A new window is displayed to review the corresponding report.



4.3 File Validation Failed

If the submitted file fails validation with error(s), a pop-up box appears containing the file name and message “(#) Error(s) Returned.”

1. To view the error report, click on the hyperlink. A new window is displayed to review the corresponding report.


3. If the submitted file fails validation with error(s) and warning(s), a pop-up box appears containing the file name and message “(#) Error(s) and “#” Warning(s) Returned.”

4. To view the error(s) and warning(s) report, click on the hyperlink. A new window is displayed to review the corresponding report.




Submission Engine Validation Tool Error(s) and Warning(s) Report: The report displays a maximum of 100 error(s) and/or 100 warning(s) for each file submitted. The following information will be included in the report:

• Submission Type: This includes the files submitted for REGISTRY- 2016, QCDR- 2016, QRDA1- 2016, QRDA3- 2016 or UNKNOWN.

• File Name: The submitted file name.

• Validation Run Date/Time: This includes the date and time the file was submitted for validation.

• “#” Error(s) Retrieved: This will show the number of errors in a file, with a maximum of 100 error(s) for each file submitted for validation.

• Export Error(s) to Excel: This option is available for system users to export the error message(s) in MS Excel format by clicking the Export Error(s) to Excel button.

• “#” Warning(s) Retrieved: This will show the number of warnings in a file, with a maximum of 100 warning(s) per display.

• Export Warning(s) to Excel: This option is available for system users to export the error message in MS Excel format by clicking the Export Warning(s) to Excel button.

• LineNumber: The line number of the XML file content, where the error was detected.

• ErrorCode: The error code associated with the error messages.

• MessageDetails: The message detail provides the details of the element that failed the specification and/or validation process.

• XPath(if applicable): This column will provide the approximate location of the error(s) detected in the XML specification during the validation process.



NOTE: After selecting the export option, a prompt will appear to 'Open, Save, or Cancel' the action. Select the 'Save' option to download the document to your desktop. Do NOT select the 'Open' option. After the file has downloaded, click on the file to open it in Microsoft Excel.

4.4 Submitting a ZIP File for Validation

To submit a Zip file for validation:

1. On the SEVT home page, in the Participation Year field, the default option selected is 2016.

2. To upload a file, click the Browse button to attach the Zip file. The uploaded Zip file should not exceed 20 MB in size.

3. Click the Validate button to process the file.

4. To clear the selected file field, click the Reset button.

The Zip file validation processes the ‘compressed’ files in batches. A pop-up box appears containing the file name and message: “Please check the email account associated with your EIDM Account for information about this submission (Batch ID ‘#’) status.”




4.5 Program Year 2016 Specifications

The Program Year 2016 Specifications section at the bottom of the SEVT Home Page contains links to the following reference documents associated with the Program Year 2016 Specifications and PQRS Error Messages:

• Registry XML Specification - Opens the Registry XML Specification and Error Messages.

• QCDR XML Specification - Opens the QCDR XML Specification and Error Messages.

• QRDA CMS IG Specifications - Opens the QRDA-1 and QRDA-3 CMS Implementation Guide Specifications.

• PQRS Error Messages (see SEVT User Guide) - Opens this guide where all PQRS error messages are documented.



SEVT Home Page:

NOTE: The above documents can also be accessed from the links provided in the Referenced Documents section of this User Guide.

The XML Schema Definition (XSD) files may only be downloaded from the online version of this XML Specification; they are not downloadable from the PDF file.

• Right-click to download the XSD files for Registry: XSD Files 2016 Registry

• Right-click to download the XSD files for QCDR: XSD Files 2016 QCDR

4.6 Batch Validation Results

The results from the SEVT Zip (batch) file validation will be compiled and emailed to the email address associated with the submitter’s CMS Identity Management System account.

CMS XLC Troubleshooting & Support


5. Troubleshooting & Support In this topic, you will learn about:

Troubleshooting Tips

Error Messages

PQRS Error Messages

System Generated Error Messages

Special Considerations

Support

5.1 Troubleshooting Tips

• To download a free copy of Adobe Acrobat Reader, click the Adobe Acrobat Reader link on the Adobe website, https://www.adobe.com.

• To view the error reports described in this manual, either turn off the web browser’s pop-up blocker or temporarily allow pop-up files.

• For help with the QSP [or the CMS Identity Management System account registration process (such as forgotten ID, password resets, etc.,)], contact the QualityNet Help Desk at 1-866-288-8912 or Qnet Support, [email protected]

https://www.adobe.com/

mailto:[email protected]




5.2 Errors Generated in User Interface (UI) Screen

Action Error message

If the user does not select a File before clicking the ‘validate’ button

A file cannot be null or empty. Please select appropriate file.

Only an XML or Zip file type may be selected for Validation in the SEVT. Selecting any file type other than XML or Zip will result in this message being displayed.

Only an XML or Zip file type may be selected for validation. Please select a different file and then click the ‘validate’ button.

If the user attempts to upload files larger than 20MB for a single XML fileor 20 MB single Zip file format.

The maximum file upload size exceeds 20 MB for individual XML file or 20 MB for individual Zip file.

If the user uploads an XML file or Zip file that contains error(s) Or warning(s) message(s).

(#)Error(s) and (#) warning(s) returned. Click on Hyperlink to view report. Click OK button to validate another file.

If the user is inactive for an extended period of time, the system will display the message.

Your session has timed out due to inactivity.

When system or service is down File Upload Transmission Failed. Please try later or Contact your System Administrator.



5.2.1 PQRS Error Messages

Message Number Error Message Condition Submission Type

Message Type

PQRS_1015 Submission Method is invalid for the given Submission Type (PQRS_1015).

Submission method is invalid for the Submission Type. For a Submission Type "2" [Group Practice Reporting Option (GPRO) Registry Submission], a valid Submission Method is "G."

REGISTRY ERROR

PQRS_1089 Measure Group Statistic (<measure-group-stat>) element is required when Measure Group ID does not equal X (PQRS_1089).

The Measure Group Statistic element cannot be blank when Measure Group ID does not equal "X."

REGISTRY ERROR

PQRS_1096 Measure Group Statistic (<measure-group-stat>) element is not valid with the Measure Group ID (PQRS_1096).

Measure Group Statistic element tag is not valid with Measure Group ID is "X."

REGISTRY ERROR

PQRS_1108 Email Address is not an allowable value (PQRS_1108).

A typical valid Email Address format is [email protected].

REGISTRY ERROR

PQRS_1109 Eligible Instances cannot be less than Meets Performance Instances (PQRS_1109).

Eligible Instances is less than Meets Performance Instances.

REGISTRY ERROR




Message Type

PQRS_1110 The Performance Rate for a measure or measure stratum should be NULL when the Performance Denominator and Performance Numerator is 0 (PQRS_1110).

The Performance Rate for a measure or measure stratum is NULL when the Performance Denominator (Eligible Instances minus Performance Exclusions) and Performance Numerator is 0.

REGISTRY ERROR

PQRS_1111 Reporting Rate is required when the Measure Group is X (PQRS_1111).

The Measure Group is "X" and Reporting Rate is Null.

REGISTRY ERROR

PQRS_1112 Measure Group ID is not valid for Submission Method (PQRS_1112).

The Measure Group ID equals "X" and submission method does not equal A.

REGISTRY ERROR

PQRS_1118 GPRO Type is not an allowable value for given submission type (PQRS_1118).

When Submission Type is 2 (i.e. GPRO Registry Submission), the value must be a valid GPRO Type value (A or B or C) given. When Submission Type is 1 (i.e. 1. Individual Registry Submission), the GPRO Type this value must be null use (<gpro-type xsi:nil="true"/>).

REGISTRY ERROR

PQRS_1121 Group Reporting Rate Numerator cannot be greater than Group Eligible Instances (PQRS_1121).

Group Reporting Rate Numerator (group-reporting-rate-numerator ) should be less than or equal to Group Eligible Instances (group-eligible-instances).

REGISTRY ERROR




Message Type

PQRS_1123 PQRS Measure Details (<pqrs-measure-details>) element tag must repeat by the number of strata for the measure as defined in the Measure Specification (PQRS_1123).

PQRS Measure details element tag does not repeat by the number of strata specified in the measure specification.

REGISTRY ERROR

PQRS_1128 The PQRS Measure Number submitted is not a valid Registry Measure for this program year (PQRS_1128).

Measure number is invalid for Registry submission for the current program year.

REGISTRY ERROR

PQRS_1129 The PQRS Measure Number does not belong to the Measure Group submitted (PQRS_1129).

PQRS Measure Number does not belong to the measure group.

REGISTRY ERROR

PQRS_6032 Email Address is not an allowable value (PQRS_6032).

A typical valid Email Address format is [email protected].

QCDR ERROR

PQRS_6067* QCDR Name does not match with the QCDR Participation File list received from CMS for Submission (PQRS_6067).

QCDR Name (case insensitive) is not an exact match within the QCDR Participation File.

QCDR ERROR




Message Type

PQRS_6069 Proportion Measure Detail (< proportion- measure-detail>) element tag must repeat by the number of performance rates for the measure as defined in the measure specification (PQRS_6069).

Proportion Measure Detail element tag does not repeat by the number of performance rates specified in the measure specification.

QCDR ERROR

PQRS_6085 Measure is a Proportion measure and must contain only Proportion Measure Detail elements (PQRS_6085).

Proportion measure must contain only Proportion Measure Detail elements.

QCDR ERROR

PQRS_6086 Measure is a Continuous measure and must contain only Continuous Measure Detail elements (PQRS_6086).

Continuous measure must contain only Continuous Measure Detail elements.

QCDR ERROR

PQRS_6105* Measure not approved for this QCDR (PQRS_6105).

The vendor in the participation file is not approved by CMS to submit for this measure.

QCDR ERROR

PQRS_6115 File includes Risk Adjusted data elements that do not apply to the associated measure. (PQRS_6115).

Risk Adjusted Measure Detail elements are not allowed for this measure.

QCDR ERROR




Message Type

PQRS_6131 Continuous Measure Detail (<continuous-measure-detail>) element tag must repeat by the number of strata for the measure as defined in the measure specification (PQRS_6131).

Continuous Measure Detail element tag does not repeat by the number of strata specified in the measure specification.

QCDR ERROR

PQRS_6149 Measure not reportable through identified measure reporting option (PQRS_6149).

The measure is not allowed for the given reporting option.

QCDR ERROR

PQRS_6150 Measure Number is not valid for current program year (PQRS_6150).

The non-PQRS measure does not match as specified in the participation file for the QCDR.

QCDR ERROR




Message Type

PQRS_10700 The CMS EHR QRDA Report SHALL conform to the CDA standard. + xmlError.getMessage(). The specifications must conform to the HL7 Implementation Guide for CDA Release 2: Quality Reporting Document Architecture Category I, Release 1, Draft Standard for Trial Use (DSTU) Release 3, US Realm, June 2015. HL7 Implementation Guide for CDA Release 2: Quality Reporting Document Architecture, Category III, DSTU Release 1, November 2012 and its July 2014 errata update for the 2016 reporting year (PQRS_10700).

Only documents that are valid against the Clinical document Architecture (CDA) schema enhanced to support the sdtc namespace (CDS_SDTC.xsd) will be accepted for processing.

QRDA-I QRDA-III

ERROR




Message Type

PQRS_10702* The submission deadline for the program initiative has passed. Files are no longer being accepted (PQRS_10702).

The user submitted XML files after the submission deadline for the program initiative has passed.

QRDA-I QRDA-III QCDR REGISTRY

ERROR

PQRS_10703* A System error has occurred while processing your file. Please contact the QualityNet Help Desk for more information (PQRS_10703).

General exception catch that occurs during processing. Ex. Exception during persistence or SIE handling.


ERROR

PQRS_10703A* Error persisting data. Please contact the QualityNet Help Desk for more information (PQRS_10703A).

A back-end system error occurred while persisting data.


ERROR

PQRS_10703B Unable to determine File Submission ID (PQRS_10703B).

Zip file may be corrupted, or an individual file did not match any submission types, or a low level exception occurred. Note: This message occurs only when there is a system runtime error.


ERROR




Message Type

PQRS_10705 Invalid date and/or time format (PQRS_10705).

Invalid Date and/or Time format. • Does not conform to the specifications • Leap year check

Registry QCDR QRDA-I QRDA-III

ERROR

PQRS_10709 The CMS program name supplied in the QRDA Category 1 data file is invalid for the PQRS system. Valid CMS program names for QRDA Category 1 PQRS processing are: PQRS_MU_INDIVIDUAL and PQRS_MU_GROUP (PQRS_10709).

The CMS program name supplied in the QRDA Category 1 data file is invalid for the PQRS system. Valid CMS program names for QRDA Category 1 PQRS processing are: PQRS_MU_INDIVIDUAL and PQRS_MU_GROUP.

QRDA-I ERROR

PQRS_10710 ValueSet validation failed. The provided code, codeSystem, and valueSet are incompatible or the valueSet is from the wrong QDM Category (PQRS_10710).

The provided code, associated with the provided codeSystem, must be in the provided valueSet. In addition, the provided valueSet must be in the QDM Category associated with the section template ID that the code was entered for.

QRDA-I ERROR

PQRS_10712 The maximum allowable length cannot exceed [nn] (PQRS_10712).

The data should be less than or equal to the specified length as per the database design. The XPATH in the error message identifies the correct location of the data element.

QRDA-I QRDA-III ERROR




Message Type

PQRS_10713 Invalid Submission Type. The valid submission types are 'PQRS-REGISTRY' or 'PQRS-QCDR' or specific to QRDA Category Report Template Id's (PQRS_10713).

The system shall validate the submission type. The system distinguishes between QRDA Category I and QRDA Category III document by the presence of the following Template Ids: QRDA Category-I: 2.16.840.113883.10.20.24.1.1:2014-12-01 QRDA Category-III: 2.16.840.113883.10.20.27.1.2


ERROR

PQRS_10714 Illegal character found at or near line [nn] (PQRS_10714).

Unable to parse the XML file due to illegal UTF-8 encoding characters in the file.


ERROR

PQRS_10716 For PQRS the HIC number, in a valid format, is required for Medicare patients. The HIC number is not allowed for non-Medicare patients (PQRS_10716).

In QRDA-1, a HIC number is required for Medicare patients and it is not allowed for non-Medicare patients. If the HIC number is provided, it must be in a valid format.

QRDA-I ERROR

PQRS_10717* The CPC Site Id provided in the data file is not valid (PQRS_10717).

In QRDA-3, the CPC Site ID provided in the XML file must exist in the CMS Approved CPC Practice Site ID list.

QRDA III ERROR




Message Type

PQRS_10722 Invalid eMeasure Version Specific Identifier for the reporting program year 2016 as published in the June, 2015 eCQM measures definitions (PQRS_10722).

The eMeasure Version Specific Identifier does not match with the 2015 eCQM specification list.

QRDA-I QRDA-III

ERROR

PQRS_10723 The measure Version Specific Identifier [Measure Version Specific Identifier] was specified more than ONE time in the data file (PQRS_10723).

Measure Version Specific Identifier is specified more than once in the XML.

QRDA-I QRDA-III

ERROR

PQRS_10724 Performance rate should be specified as REAL number and value should be less than or equal to 1.0 (PQRS_10724).

Performance rate is not specified as a REAL number and value is not less than or equal to 1.0.

QRDA-III ERROR

PQRS_10725 The required number of performance rates, per measure, were not found for a multi-performance rate measure (PQRS_10725).

The required number of performance rates in a QRDA-III file submission are not included for a multi-performance rate measure.

QRDA-III ERROR

PQRS_10726 The numerator is NOT less than or equal to the denominator for a proportion measure (PQRS_10726).

The numerator is NOT less than or equal to the denominator for a proportion measure.

QRDA-III ERROR




Message Type

PQRS_10727 The submitted performance numerator is NOT less than or equal to the calculated performance denominator (PQRS_10727).

The submitted numerator is greater than the calculated performance denominator (calculated performance denominator = (DENOM – DENOM EXCL – DENOM EXCEP) for proportion measures in a QRDA III file submission.

QRDA-III ERROR

PQRS_10728 The combined length of all the raceCode elements with comma delimiters shall not exceed the maximum allowable length of 256 characters (PQRS_10728).

The combined length of all the raceCode elements with comma delimiters exceed length of 256 characters.

QRDA-I ERROR

PQRS_10729 The measure population is NOT less than or equal to the Initial Patient Population for a continuous variable measure (PQRS_10729).

The measure population (MSRPOPL) is not less than or equal to the Initial Patient Population (IPP) for a continuous variable measure submitted via QRDA-III or QCDR.

QRDA-III QCDR

ERROR




Message Type

PQRS_10730 A System error has occurred while executing the [VALIDATION STEP] rule. Please contact the QualityNet Help Desk for more information (PQRS_10730).

Possible Values for “Validation Step” include: • SchematronValidationRule • GproValidationRule • CPCValidationRule • SchemaValidationRule • AcoValidationRule • Qrda1ProdDateCutoffValidationRule • Qrda3ProdDateCutoffValidationRule • RegistryProdDateCutoffValidationRule • QcdrProdDateCutoffRule • RegistryValidationRule2016 • QcdrValidationRule2016 • QcdrAltMsrNumValidationRule2016 • QcdrVendorValidationRule2016 Note: This message occurs only when there is a system runtime error.


ERROR

PQRS_10732 The Performance rate for a proportion measure or measure stratum is NOT NULL when the calculated performance denominator is 0 (PQRS_10732).

The system will verify that the performance rate for a proportion measure or measure stratum is Null when the calculated performance denominator (DENOM – DENOM EXCL – DENOM EXCEP) is 0, for a QRDA III file submission with a CMS Program Name of CPC.

QRDA-III ERROR




Message Type

PQRS_10733 The performance rate for a proportion measure or measure stratum does not = (NUMER / (DENOM – DENOM EXCL – DENOM EXCEP)) when the performance denominator is greater than 0 (PQRS_10733).

The system will verify that the performance rate for a proportion measure or measure stratum provided = (NUMER / (DENOM – DENOM EXCL – DENOM EXCEP)) when the calculated performance denominator (DENOM – DENOM EXCL – DENOM EXCP) is greater than 0, for a QRDA III file submission with a CMS Program Name of “CPC.”

QRDA-III ERROR

PQRS_10734 At least nine (9) CPC measures are required when submitting as a CPC program (PQRS_10734).

The QRDA III file with a CMS Program Name “CPC” includes less than 9 CPC measures.

QRDA-III ERROR

PQRS_10735 The denominator is greater than the Initial Patient Population (PQRS_10735).

When the denominator is greater than the Initial Patient Population (initial population) in QRDA III and QCDR file submissions.

QRDA-III QCDR

ERROR

PQRS_10739 Warning: None of the submitted measures include Medicare patient data in the denominator. The PQRS satisfactory reporting criteria requires at least one measure containing Medicare patient data. Please contact the Helpdesk with questions (PQRS_10739).

The QRDA III file submission with a CMS Program Name of “PQRS_MU_INDIVIDUAL” or “PQRS_MU_GROUP” does not include Medicare payer data in the denominator for any of the proportion measures OR in the measure population of the continuous variable measure.

QRDA-III WARNING




Message Type

PQRS_10757* Warning: TIN is registered for the Group Practice Reporting Option. Data was accepted but may not be evaluated for PQRS satisfactory reporting. Contact the QualityNet Help Desk with questions (PQRS_10757).

The TIN(s) included in the XML file is not found on the Group Practice Finder File.


WARNING

PQRS_10758* Warning: Provider TIN was identified as belonging to an MSSP ACO. MSSP ACOs must report PQRS via Web Interface at the ACO level. Contact the QualityNet Help Desk with questions (PQRS_10758).

Verify that the TIN(s) included in the XML file is not found on the ACO Finder File.


WARNING

PQRS_10759 The Performance Numerator should be less than or equal to Reporting Denominator (PQRS_10759).

Performance Numerator is greater than Reporting Denominator.

QCDR ERROR

PQRS_10761 Duplicate population templates have been found in the submitted data [BAD_GUID_LIST] (PQRS_10761).

For QRDA-3 only; Duplicate population templates occurred in the XML file.

QRDA-III ERROR




Message Type

PQRS_10762 The Reporting Period date is not within the current reporting period range, January 1st 2016 through December 31st 2016 (PQRS_10762).

The Reporting Parameters dates being reported in XML is out of range for the current reporting period.

QRDA-I ERROR

PQRS_10763 SHALL contain a GUID value that is valid for this population. [Offending GUID value] (PQRS_10763).

Each population must have a valid GUID as defined in the June 2015 measure specifications for 2016.

QRDA-III ERROR

PQRS_10764 SHALL be [1..1] performance rate template for each distinct [NUMERATOR GUID] value. [performance rate] (PQRS_10764).

Each performance rate is tied to a corresponding distinct numerator. No duplicate performance rate templates are allowed in the submission.

QRDA-III ERROR

PQRS_10765 An invalid number of population templates have been found in the submitted data: [Measure Version ID], [Population GUID], [Population Code], [Group] (PQRS_10765).

If the number of populations is not equal to the number of populations defined for the eCQM in the July 2015 eCQM Specifications for 2016.

QRDA-III ERROR

PQRS_10770 Each individual file contained in an uploaded zip file shall not exceed 40 MB in size when uncompressed (PQRS_10770).

Each individual file contained in an uploaded zip file shall not exceed 40 MB in size when uncompressed.


ERROR




Message Type

PQRS_10771 Unable to process an empty file (PQRS_10771).

File has 0 bytes. QRDA-I QRDA-III QCDR REGISTRY

ERROR

PQRS_10772 An encrypted or corrupted ZIP file was submitted. The system is unable to process this file (PQRS_10772).

When zip file is encrypted or password protected or unable to read the zip file.


ERROR

PQRS_10774 Encounter From Date cannot be greater than Encounter To Date (PQRS_10774).

Encounter From Date cannot be greater than Encounter To Date.

QCDR REGISTRY

ERROR

PQRS_10775 [Data Element Name] has an invalid day for the given month and year (PQRS_10775).

Invalid calendar date. QCDR REGISTRY

ERROR

PQRS_10776 Performance Numerator should be less than or equal to the calculated Performance Denominator (PQRS_10776).

Submitted Performance Numerator is greater than the calculated Performance Denominator.

QCDR REGISTRY

ERROR




Message Type

PQRS_10779* NPI must be in the correct format. A valid NPI is 10 numeric digits. The 10th digit is a check digit computed using the Luhn algorithm. Note: For the Eligible Professional (EP) programs, NPI is required except for the Group Practice Reporting Option (GPRO). For GPRO, use null indicator for NPI (PQRS_10779).

NPI follows the Luhn Algorithm (during Submissions only).

QCDR REGISTRY

ERROR

PQRS_10780 Measure Stratification Number must be within the range defined in the measure specification (PQRS_10780).

Measure Stratification Number is out of range.

REGISTRY QCDR

ERROR




Message Type

PQRS_10781 Warning: At least one proportion measure has been submitted with a 0% (0.0) performance rate. Proportion measures reported with a 0% performance rate through the QCDR or Registry do not count as satisfactorily reported for PQRS. Please contact the Helpdesk with questions (PQRS_10781).

The proportion measure or measure stratum reported via QCDR or Registry has a submitted performance rate of 0.0.

REGISTRY QCDR

WARNING

PQRS_10782 Warning: At least one inverse proportion measure has been submitted with a 100% (100.0) performance rate. Inverse proportion measures reported with a 100% performance rate through the QCDR or Registry do not count as satisfactorily reported for PQRS. Please contact the Helpdesk with questions (PQRS_10782).

The inverse proportion measure or measure stratum reported via QCDR or Registry has a submitted performance rate of 100.0.

REGISTRY QCDR

WARNING




Message Type

PQRS_10783 Duplicate Measure Stratification Number is not allowed (PQRS_10783).

Submission contains more than one instance of the same strata number for the same measure.

QCDR REGISTRY

ERROR

PQRS_10802 The QRDA-I file submission with the Program Name PQRS_MU_GROUP includes an NPI (PQRS_10802).

The QRDA I file submission with the Program Name PQRS_MU_GROUP includes an NPI.

QRDA-I ERROR

PQRS_10803 The QRDA-I file submission with the Program Name PQRS_MU_GROUP includes more than one TIN (PQRS_10803).

The QRDA I file submission with the Program Name PQRS_MU_GROUP includes more than one TIN.

QRDA-I ERROR

PQRS_10804 The QRDA-I file submission with the Program Name PQRS_MU_INDIVIDUAL includes more than one NPI (PQRS_10804).

The QRDA I file submission with the Program Name PQRS_MU_INDIVIDUAL includes more than one NPI.

QRDA-I ERROR




Message Type

PQRS_10805 The QRDA-I file submission with the Program Name PQRS_MU_INDIVIDUAL includes more than one TIN (PQRS_10805).

The QRDA I file submission with the Program Name PQRS_MU_INDIVIDUAL includes more than one TIN.

QRDA-I ERROR

PQRS_10806 The QRDA-I file submitted with the Program Name PQRS_MU_INDIVIDUAL does not include an NPI (PQRS_10806).

The QRDA I file submitted with the Program Name PQRS_MU_INDIVIDUAL does not include an NPI.

QRDA-I ERROR

PQRS_10808 The [QRDA CATEGORY] file submission has the INVALID Program Identifier Pioneer ACO (PQRS_10808).

The [QRDA CATEGORY] file submission has the Program Identifier “Pioneer ACO.”

QRDA-I ERROR

PQRS_10809 The QRDA-III file submission with the Program Name CPC includes more than one Practice Site ID (PQRS_10809).

The QRDA III file submission with the Program Name CPC includes more than one Practice Site IDs.

QRDA-III ERROR

PQRS_10810 The QRDA-III file submission with the Program Name MU_ONLY includes more than one NPI (PQRS_10810).

The QRDA III file submission with the Program Name MU_ONLY includes more than one NPI.

QRDA-III ERROR




Message Type

PQRS_10811 The QRDA-III file submission with the Program Name MU_ONLY includes more than one TIN (PQRS_10811).

The QRDA III file submission with the Program Name MU_ONLY includes more than one TIN.

QRDA-III ERROR

PQRS_10812 The QRDA-III file submission with the Program Name PQRS_MU_GROUP includes an NPI (PQRS_10812).

The QRDA III file submission with the Program Name PQRS_MU_GROUP includes an NPI.

QRDA-III ERROR

PQRS_10813 The QRDA-III file submission with the Program Name PQRS_MU_GROUP includes more than one TIN (PQRS_10813).

The QRDA III file submission with the Program Name PQRS_MU_GROUP includes more than one TIN.

QRDA-III ERROR

PQRS_10814 The QRDA-III file submission with the Program Name PQRS_MU_INDIVIDUAL includes more than one NPI (PQRS_10814).

The QRDA III file submission with the Program Name PQRS_MU_INDIVIDUAL includes more than one NPI.

QRDA-III ERROR

PQRS_10815 The QRDA-III file submission with the Program Name PQRS_MU_INDIVIDUAL includes more than one TIN (PQRS_10815).

The QRDA III file submission with the Program Name PQRS_MU_INDIVIDUAL includes more than one TIN.

QRDA-III ERROR




Message Type

PQRS_10824* The TIN included in a [SUBMISSION_TYPE] file submission with the Program Name [PROGRAM_NAME] is found in a Group Practice list (PQRS_10824).

[SUBMISSION_TYPE] can be QRDA I, QRDA III, REGISTRY, QCDR. PROGRAM_NAME is the name of the program the file submitted as REPORTING_OPTION is Registry, EHR.


ERROR

PQRS_10825* The TIN included in a [SUBMISSION_TYPE] file submission with the Program Name [PROGRAM_NAME] is not found in the Group Practice list (PQRS_10825).

The TIN is not found in the GPRO Finder File.


ERROR

PQRS_10826* The TIN included in a [SUBMISSION_TYPE] file submission with the Program Name [PROGRAM_NAME] is not found to be registered for [REPORTING_OPTION] in the Group Participation File (PQRS_10826).

Where: [SUBMISSION_TYPE] can be QRDA I, QRDA III, REGISTRY, QCDR PROGRAM_NAME is the name of the program the file submitted as REPORTING_OPTION is Registry, EHR.


ERROR




Message Type

PQRS_10827* The [SUBMISSION_TYPE] file submitted with the Program Name [PROGRAM_NAME] includes a TIN that was found to be either an MSSP ACO Primary TIN and/or an MSSP ACO Participant TIN (PQRS_10827).

[SUBMISSION_TYPE] can be QRDA I, QRDA III, REGISTRY, QCDR PROGRAM_NAME is the name of the program the file submitted as REPORTING_OPTION is Registry, EHR.

QRDA-I QRDA-III

ERROR

PQRS_10829 The QRDA-III file submitted with the Program Name PQRS_MU_INDIVIDUAL does not include an NPI (PQRS_10829).

The QRDA III file submitted with the Program Name PQRS_MU_INDIVIDUAL does not include an NPI.

QRDA-III

ERROR

PQRS_10830 File includes a duplicate measure for a provider or group practice (PQRS_10830).

Duplicate Measure Number in XML for a Provider.

QCDR REGISTRY

ERROR

PQRS_10832* Vendor Unique ID is not in the list of approved vendors registered for Submissions by CMS (PQRS_10832).

Vendor Unique ID is not an exact match within the Participation File.

QCDR REGISTRY

ERROR

PQRS_10833 SHALL contain a GUID value that is valid for this reporting stratum. [Offending GUID value] (PQRS_10833).

Each population stratum must have a valid GUID as defined in the June 2015 measure specifications for 2016.

QRDA-III ERROR




Message Type

PQRS_10834 An invalid number of reporting stratum templates have been found in the submitted data: [stratum GUIDS](PQRS_10834).

If the number of population stratum is not equal to the number of population stratum defined for the eCQM in the July 2015 ECQM Specifications for 2016.

QRDA-III ERROR

PQRS_10835 Invalid character set encoding. Encoding for the XML file must be UTF-8 (PQRS_10835).

The encoded XML file is not UTF-8. QRDA-I QRDA-III QCDR REGISTRY

ERROR

PQRS_10836 Provider NPI (<npi>) value is required for Individual Submission (PQRS_10836).

Provider NPI element tag is required for Individual Submission.

QCDR REGISTRY

ERROR

PQRS_10837 Provider NPI (<npi>) value must be null for GPRO Submission (PQRS_10837).

When 10 digit NPI number is populated by GPRO Submission. For Group submission, use null indicator as <npi xsi:nil="true" />.

QCDR REGISTRY

ERROR

PQRS_711206 This id SHALL equal the eMeasure’s measure observation definition (PQRS_711206).

This id SHALL equal the eMeasure’s measure observation definition.

QRDA-III ERROR

* Validation for this message is disabled for SEVT; it is enabled only for Submissions.



5.2.2 System Generated Error Messages

If the SEVT presents the following error message, contact the QualityNet Help Desk:

• File Upload Transmission Failed. Please try later or Contact your System Administrator.

Provide information to the help desk regarding the error message. In addition, if the error occurred while attempting to validate a file, provide the file to the help desk. NOTE: The file cannot contain PHI or PII.

For information about data submission, file specifications, and reporting methods, refer to the CMS PQRS Website (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/pqrs/index.html).

5.3 Special Considerations

Not applicable.

5.4 Support

Contact Org Phone Email Role Responsibility

CMS IT Service Desk

CMS 410-786-2580 or 1-800-562-1963

CMS IT Service Desk, [email protected]

Help desk support

First level user support & problem reporting

QualityNet Help Desk

HCQIS 1-866-288-8912 QualityNet Support Email Address, [email protected]

Help desk support

Help with the Portal or the CMS Identity Management System registration process (e.g., forgot ID, password resets, etc.,)

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/pqrs/index.html

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/pqrs/index.html











CMS XLC Acronyms


Acronyms

Acronym Literal Translation

ACO Accountable Care Organization

CDA Clinical Document Architecture

CMS Centers for Medicare & Medicaid Services

CPC Comprehensive Primary Care

EHR Electronic Health Record

DSTU Draft Standard for Trial Use

DSV Data Submission Vendor

eCQM Electronic Clinical Quality Measure

EIDM CMS Enterprise Identity Management system

EP Eligible Professional

GPRO Group Practice Reporting Option

HIC Health Insurance Claim

IPP Initial Patient Population

MFA Multi-Factor Authentication

MMSEA Medicare, Medicaid, and SCHIP Extension Act

MIPPA Medicare Improvements for Patients and Providers Act

MSSP Medicare Shared Savings Program

NPI National Provider Identifier

PFS Physician Fee Schedule

PHI Personal (or Protected) Health Information

PII Personally Identifiable Information

PDF Portable Document Format

CMS XLC Acronyms


Acronym Literal Translation

PQRS Physician Quality Reporting System

QCDR Qualified Clinical Data Registry

QSP QualityNet Secure Portal

QRDA Quality Reporting Data Architecture

QRDA I Quality Reporting Data Architecture Category I (also referenced as QRDA 1 or QRDA Category 1)

QRDA III Quality Reporting Data Architecture Category III (also referenced as QRDA 3 or QRDA Category 3)

SEVT Submission Engine Validation Tool

TIN Tax Identification Number

TRHCA Tax Relief Health Care Act

UI User Interface

XSD XML Schema Definition

CMS XLC Glossary


Glossary

Term Definition

Centers for Medicare & Medicaid Services (CMS)

A federal agency within the U.S. Department of Health and Human Services responsible for administering Medicare, working with state governments on administering Medicaid, the State Children’s Health Insurance Program (SCHIP), and health insurance portability standards.

Electronic Health Record (EHR)

Electronic Health Records are electronic records of patient health information gathered and/or generated in any care delivery setting. This information includes patient demographics, progress notes, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports. Gathering and/or generating this information electronically provides the ability for providers to pass information from care point to care point and ensure quality health management by physicians.

Eligible Professionals (EP)

Within PQRS, covered professional services are those paid under or based on the Medicare Physician Fee Schedule. To the extent that eligible professionals are providing services that are paid under or based on the Physician Fee Schedule, those services are eligible for the Physician Quality Reporting System.

CMS Identity Management System (EIDM)

Service which enables CMS Business Partners a means to receive a single User ID to access many CMS applications.

Multi-Factor authentication (MFA)

Security system that requires more than one method of authentication from independent categories of credentials to verify the user's identity for a login or other transaction.

Personal (or Protected) Health Information (PHI)

Refers to demographic information, medical history, test and laboratory results, insurance information and other data that is collected by a health care professional to identify an individual and determine appropriate care

CMS XLC Glossary


Term Definition

Personally Identifiable Information (PII)

Information that can be used to distinguish or trace an individual’s identity (such as name, social security number, biometric records, etc.), alone or when combined with other personal or identifying information that is linked or linkable to a specific individual (such as date and place of birth, mother’s maiden name, etc.). Personally Identifiable Information (PII) includes individually identifiable health information as defined by the HIPAA Privacy Rule (45 CFR Section 164.501). PII is also often referred to as personally identifiable data or individually identifiable information.

Physician Quality Reporting System (PQRS)

A quality reporting system that includes an incentive payment for eligible professionals who satisfactorily report data on quality measures for covered professional services provided during the specified program year.

User Person who utilizes the product directly via the user interface.

CMS XLC Referenced Documents


Referenced Documents

Document Name Document Number or URL Issuance Date

CMS Implementation Guide for Quality Reporting Document Architecture Category I and Category III Eligible Professional Programs and Hospital Quality Reporting (HQR) Supplementary Implementation Guide for 2016

https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/QRDA_2016_CMS_IG.pdf

July 2015

HL7 Implementation Guide: Decision Support Service, Release 1.1 January 2016

http://www.hl7.org/implement/standards/product_brief.cfm?product_id=334

January 2016

HL7 Implementation Guide for CDA Release 2: Quality Reporting Document Architecture, Category I, Draft Standard for Trial Use Release 3 (QRDA-I R3). June 2015


July 2015

Qualified Clinical Data Registries (QCDR) XML Specifications

https://www.qualitynet.org/imageserver/qcdr/QCDRXMLSpec2016/index.htm

July 2016

Registry XML Specifications https://www.qualitynet.org/imageserver/registry/RegistryXMLSpec2016/index.htm

July 2016










https://www.qualitynet.org/imageserver/registry/RegistryXMLSpec2016/index.htm

https://www.qualitynet.org/imageserver/registry/RegistryXMLSpec2016/index.htm

CMS XLC Record of Changes


Record of Changes

Version Date Description

1.0 10/06/16 Initial version for the PQRS September (10.3.0) release.

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