Quality Reporting for Primary Care First (PCF)

Posted on May 6, 2022

Practices participating in the Primary Care First (PCF) program must meet annual Quality data reporting requirements. Quality data must be submitted to the Centers for Medicare and Medicaid Services (CMS) in a specified PCF QRDA III format which may be a challenge for some practices. If your electronic health record (EHR) system is unable to aggregate data at the practice site level or if you need to aggregate data across 2 different EHRs, MDinteractive can help by converting your Quality data into the acceptable format. You can find more information about the PCF QRDA III format here.

PCF Quality Reporting Overview

CMS requires annual quality measure tracking and reporting as part of the PCF program. Participating practices must collect and report data for specific quality measures for the entire performance year (January - December). 

PCF eCQM Reporting Requirements 

To qualify for a positive performance-based adjustment, practices must meet or exceed average national performance thresholds on a limited set of quality measures that are clinically meaningful for patients. PCF uses one claims-based measure (Advance Care Planning) and three electronic Clinical Quality Measures (eCQMs) that are generated from an EHR. 

eCQMs use data captured from an EHR in structured formats (e.g., data that are entered into specific fields) at the point of patient care. The intent of eCQMs is to help measure and track the quality of health care services provided by the clinician or practice. MDinteractive is a CMS Qualified Registry and is certified by the Office of the National Coordinator for Health Information Technology (ONC) to generate eCQMs used for PCF.  



#001: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)

Reported for patients aged 18-75 years with diabetes who had hemoglobin A1c > 9.0% during the measurement period.

#113: Colorectal Cancer Screening

Reported for patients 50-75 years of age who had appropriate screening for colorectal cancer.

#236: Controlling High Blood Pressure

Reported for patients 18 - 85 years of age who had a diagnosis of hypertension overlapping the measurement period and whose most recent blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period.

QRDA File Format

For PCF, eCQMs must be reported in a PCF Quality Reporting Document Architecture (QRDA) III file.  QRDA is an HL7 Clinical Document Architecture (CDA) based standard that can be used for electronically sharing quality measure data. QRDA creates a standard method to report quality measure results in a structured, consistent format and can be used to exchange eCQM data between systems. 

There are two types of QRDA files that can be generated from an EHR:

  • QRDA I (Single Patient Report): This file format includes individual patient level data and contains quality data for one patient for one or more eCQMs.
  • QRDA III (Calculated Report): This file format includes an aggregate quality report that contains quality data for a set of patients for one or more eCQMs. The data is aggregated from individual QRDA I reports.  No patient level data is included in these reports.

PCF QRDA III File Format

The PCF eCQMs must be reported using a special QRDA III format and not the QRDA III format commonly used for individual clinician or group reporting under the Merit-based Incentive Payment System (MIPS). The PCF QRDA III file must contain the following unique identifiers:

  • CMS Program Name of “PCF”
  • APM Entity Identifier, which is equivalent to your PCF Practice ID (e.g., OR1234)
  • Practice site address
  • NPI and TIN combinations, as indicated in your practice’s PCF practitioner roster
  • CMS EHR Certification ID
  • Performance year start date of “20220101”
  • Performance year end date of “20221231”
  • Performance rate for each measure, reported as a decimal (i.e., 1 is equivalent to 100 percent)
  • All eCQM data elements (i.e., Initial Population, Denominator, Denominator Exclusions, Numerator) for each measure, reported with the appropriate universally unique identifier (UUID) for each
  • Supplemental Data Elements for each measure population

A PCF QRDA III file uploaded to QPP with a missing NPI or an incorrect identifier will generate an error or a warning message and your PCF QRDA III file may fail submission. You can find more information about the PCF QRDA III format here.

eCQM Reporting Challenges

ONC-certified EHRs can usually aggregate data at the clinician level or at the TIN level. However, some EHRs are unable to aggregate at the PCF practice site level and are unable to generate a PCF formatted QRDA III file. If this is a challenge for your practice, MDinteractive can help by converting your Quality data into the acceptable format to ensure your practice can successfully meet the PCF submission requirements.

  • We require QRDA I files with the 3 quality measures from each PCF clinician.
  • MDinteractive aggregates the data at the Practice Site level and generates the QRDA IIIs as required by the PCF program.
  • MDinteractive can give the prepared QRDA III files to your practice for submission through the Quality Payment Program (QPP) portal or MDinteractive can submit the files directly to QPP on your behalf.

Contact Us Today

MDinteractive can assist your practice with meeting the PCF eCQM reporting requirements.  We are familiar with the PCF QRDA III file format and can generate a PCF QRDA III file that contains all of the necessary data elements for the eCQMs. Contact us today to learn how we can set your practice up for successful PCF reporting.



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