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2020 MIPS measures with multiple performance rates

There are several MIPS measures that require the collection and submission of data for multiple populations. This means that there can be multiple performance rates associated with a single measure. Accordingly, these are often referred to as "multi-performance rate measures".

Historical benchmarks for multi-performance rate measures were created based on the "overall performance rate". When you are scored on a multi-performance rate measure, we will compare the "overall performance rate" of your submitted measure to the measure's benchmark which is also based on the "overall performance rate".

An overall performance rate may be determined in one of three ways:

Weighted Average (Example: Measure 370)

DENOMINATOR (SUBMISSION CRITERIA 1): Adolescent patients 12 to 17 years of age with a diagnosis of major depression or dysthymia and an initial PHQ-9 or PHQ-9M score greater than nine during the index event
Performance MET/ NUMERATOR (SUBMISSION CRITERIA 1): Adolescent patients 12 to 17 years of age with major depression or dysthymia who reached remission at twelve months as demonstrated by a twelve month (+/-60 days) PHQ-9 or PHQ-9M score of less than 5
DENOMINATOR (SUBMISSION CRITERIA 2): Adult patients aged 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 or PHQ-9M score greater than nine during the index event
Performance MET/ NUMERATOR (SUBMISSION CRITERIA 2): Adult patients 18 years of age or older with major depression or dysthymia who reached remission at twelve months as demonstrated by a twelve month (+/-60 days) PHQ-9 or PHQ-9M score of less than 5
Example
Clinician works with a Qualified Registry to collect and submit the following data for Measure 370:

20 patients in Denominator 1

18 patients in Numerator 1

30 patients in Denominator 2

24 patients in Numerator 2

No patients qualified for a denominator exception

The system calculates the overall performance rate using the numerator and denominator values

Weighted Average Calculation = [sum of numerator values] divided by [sum of denominator values]

Overall Performance Rate = (18 + 24)/(20 + 30) = .84 or 84%

Note: There is no historical benchmark for Measure 370  (MIPS CQM collection type) for the 2020 performance period. If a performance period benchmark can be calculated, it will be based on the weighted average performance rate.

 

Simple Average (Example: Measure 009)

DENOMINATOR (1 and 2): Patients 18 years of age and older who were dispensed antidepressant medications within 245 days (8 months) prior to the measurement period through the first 120 days (4 months) of the measurement period, and were diagnosed with major depression 60 days prior to, or 60 days after the dispensing event and had a visit 60 days prior to, or 60 days after the dispensing event
NUMERATOR 1: Patients who have received antidepressant medication for at least 84 days (12 weeks) of continuous treatment during the 114-day period following the Index Prescription Start Date
NUMERATOR 2: Patients who have received antidepressant medications for at least 180 days (6 months) of continuous treatment during the 231-day period following the Index Prescription Start Date
Example
Clinician uses their2015 Edition certified EHR technology to collect and submit the following data for Measure 009 (CMS 128v6):

20 patients in Denominator (1 and 2)

18 patients in Numerator 1

15 patients in Numerator 2

No patients qualified for a denominator exception

The system calculates the overall performance rate using the performance rates calculated for rates 1 and 2

Simple Average = [sum of performance rates] divided by [the number of performance rates]

Performance Rate 1: 18/20 = .900 or 90.0%

Performance Rate 2: 15/20 = .750 or 75.0%

Overall Performance Rate = (.900 + .750)/(2) = .825 or 82.5%

 

Specified Performance Rate (Example: Measure 0226 - 2nd Performance Rate)

DENOMINATOR (SUBMISSION CRITERIA 1): All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period
NUMERATOR (SUBMISSION CRITERIA 1): Patients who were screened for tobacco use at least once within 24 months
DENOMINATOR (SUBMISSION CRITERIA 2): All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period who were screened for tobacco use and identified as a tobacco user
NUMERATOR (SUBMISSION CRITERIA 2): Patients who received tobacco cessation intervention
DENOMINATOR (SUBMISSION CRITERIA 3): All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period
NUMERATOR (SUBMISSION CRITERIA 3): Patients who were screened for tobacco use at least once within 24 months AND who received tobacco cessation intervention if identified as a tobacco user
Example
Clinician works with a Qualified Registry to collect and submit the following data for Measure 226:

100 patients in Denominator 1

80 patients in Numerator 1

40 patients in Denominator 2

36 patients in Numerator 2

100 patients in Denominator 3

70 patients in Numerator 3

No patients qualified for a denominator exception.

The system determines the overall performance rate by calculating the performance rates for the measure strata or sub-components

Performance Rate 1: 80/1000 = .80 or 80%

Performance Rate 2: 36/40 = .90 or 90.0%

Performance Rate 3: 70/100 = .700 or 70.0%

Overall Performance Rate = Performance Rate 2 = 90.0%

 

Measure TitleQuality NumberOverall Performance RateNumber of Performance Rates
Anti-Depressant Medication Management009Simple Average2
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention2262nd Performance Rate3
Use of High-Risk Medications in the Elderly2381st Performance Rate2
Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents239Simple Average3
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment305Simple Average2
Implantable Cardioverter-Defibrillator (ICD) Complications Rate348Weighted Average2
Follow-Up Care for Children Prescribed ADHD Medication (ADD)366Simple Average2
Depression Remission at Twelve Months370Weighted Average2
Follow-Up After Hospitalization for Mental Illness (FUH)3912nd Performance Rate2
Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation3925th Performance Rate5
Immunizations for Adolescents3944th Performance Rate4
Optimal Asthma Control3981st Performance Rate7

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