MIPS Quality Performance Category Measures
The Quality Measures category of MIPS replaces the Physician Quality Reporting System and will contribute to 60% of your MIPS Final Score in 2017. Determine which participation method for MIPS you wish to use in 2017, and then complete the requirements associated with that participation method as outlined below.
- MIPS Test Pace Participation. Submit data for one quality measure to CMS. If you choose to report the Quality category for Test Pace participation, you must report a quality measure with at least a 1 in the denominator and 1 in the numerator in order to receive credit for this category.
- MIPS Partial Year Participation. Submit 90 days of 2017 data to Medicare for at least 6 MIPS quality measures before March 31, 2018. Of the 6 measures that are submitted, at least one must be an outcome measure or a high-priority measure.
- MIPS Full Year Participation. Submit a full year of 2017 data (January 1, 2017 through December 31, 2017) to Medicare for up to 6 MIPS quality measures before March 31, 2018. Of the 6 measures that are submitted, at least one must be an outcome measure or a high-priority measure.
Quality measures that are reported can contribute between 3-10 points towards your MIPS Final Score if they can be reliably scored against a benchmark, which means a benchmark exists for the measure, the data you reported meets minimum case number requirements (≥ 20 cases for most measures), and you have submitted at least 50% of the data possible for the measure. If a quality measure that you submit cannot be reliably scored against a benchmark, you will still earn 3 points.
Source : Centers for Medicare and Medicaid Services webinar. January 12, 2017.
To see a complete list of the 2017 MIPS quality measures, visit the CMS Quality Payment Program site. Below is a list of MIPS-eligible Electronic Clinical Quality Measures (eCQMs) that Practice Fusion plans to support in 2017:
Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.
The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a foot exam (visual inspection and sensory exam with mono filament and a pulse exam) during the measurement year
Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria:
- Women age 21-64 who had cervical cytology performed every 3 years
- Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years
Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer.
Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine
Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer.
Percentage of patients 18-75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal exam (no evidence of retinopathy) in the 12 months prior to the measurement period.
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.
Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period.
Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization.
Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12 month period.
Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period.
CMS155v5 – Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported.
- Percentage of patients with height, weight, and body mass index (BMI) percentile documentation
- Percentage of patients with counseling for nutrition
- Percentage of patients with counseling for physical activity
Percentage of patients 66 years of age and older who were ordered high-risk medications. Two rates are reported.
a. Percentage of patients who were ordered at least one high-risk medication. b. Percentage of patients who were ordered at least two different high-risk medications.
Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antiplatelet during the measurement period.
Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period
Percentage of patients 18-50 years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis.
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated
Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen
Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred
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. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.
Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter
- Normal Parameters: Age 18 years and older BMI => 18.5 and < 25 kg/m2
Percentage of patients 65 years of age and older with congestive heart failure who completed initial and follow-up patient-reported functional status assessments
Benchmarks & performance points
Quality measures that are reported can contribute 3-10 points towards a clinician’s MIPS Final Score if the measure can be reliably scored against a benchmark. According to CMS, this means:
- A benchmark exists for the measure.
- The data a clinician is reporting meets the minimum case number requirement (≥ 20 cases for most measures).
- A clinician submits at least 50% of the data possible for the measure.
If a quality measure that a clinician submits cannot be reliably scored against a benchmark, he or she will still earn 3 points for that measure if data is reported.
To determine points for each measure, CMS compares an eligible clinician’s performance to published benchmarks that are based on national performance in a baseline period. Points are assigned based on the decile range in which the clinician’s performance data falls at the end of the performance period. All scored measures receive at least 1 point and partial points are assigned within deciles based on percentile distribution. Eligible clinicians with performance in the top decile (Decile 10) will receive the maximum 10 points available for the measure. Eligible clinicians who do not report the maximum number of measures will receive 0 points for each measure not reported, unless they could not report the maximum number due to insufficient applicable measures.
The relevant benchmarks for each eCQM that the Practice Fusion EHR will support for the 2017 performance year are detailed below.
As an example, a clinician with a measure performance rate of 65% for Controlling High Blood Pressure (CMS 165v5) would fall within the Decile 6 range and receive between 6.0 and 6.9 points for that measure. A clinician with a performance rate of 85% would fall within the Decile 10 range and receive the maximum 10 points available.
Clinicians may receive bonus points for any of the following:
- 2 bonus points for each additional outcome and patient experience measure submitted.
- 1 bonus point for each additional high-priority measure submitted.
- 1 bonus point for using CEHRT to submit measures to registries or CMS.
How is the Quality performance category scored under MIPS?
The maximum Quality performance category score cannot exceed 100% and for clinicians using the Practice Fusion EHR to report on the Quality performance category, the maximum number of available points will generally be 60 (6 required measures x 10).
What if I cannot find 6 quality reporting measures relevant to my practice?
If you cannot find 6 quality reporting measures you wish to report on from those supported by Practice Fusion, you may explore other quality measure reporting mechanisms or report as many measures as you can from Practice Fusion. Under MIPS, you can receive credit for reporting any measure, up to 6, that has data in the denominator and numerator. You may also explore other quality measure reporting mechanisms that may be better for your practice, such as claims-based reporting.
What is MIPS?
MACRA combines Medicare incentive programs into one single program: the Merit-Based Incentive Payment System (MIPS).
What are APMs?
MACRA allows providers who take further steps towards transforming healthcare to be exempt from MIPS and participate in Advanced Alternative Payment Models (APMs).
How to prepare
Individual eligible providers can prepare to meet all MIPS measures and be ready to avoid penalties and earn bonuses on January 1, 2017.
All measures and definitions provided by CMS. For more information visit QPP.CMS.gov.