How to choose MIPS quality measures

  1. The following factors could be considered when deciding which measures to select for MIPS reporting:
    • Clinical conditions usually treated;
    • Types of care typically provided (e.g., preventive, chronic, acute);
    • Settings where care is usually delivered (e.g., office, emergency department [ED], surgical suite);
    • Quality improvement goals;
    • Other quality reporting programs in use or being considered;
       
  2. Find out if any of the MIPS quality specialty sets apply to your specialty. You can find our suggestions by specialty here.  
  3. Because you will need to report at least 50% of the patients/visits eligible for a measure, (ALL insurances, Medicare and not Medicare)  you could select measures with a more defined demographic in order to create a manageable size report. 
  4. There are several advantages of reporting MIPS at the group level instead of individual level:
    • Let's imagine a practice one anesthesiologist, one pathologist, one hospitalist, one internist, one dermatologist and one cardiologist. If the providers report MIPS at the individual level, one potentially would  need to manage and optimize the performance of  36 different quality measures. At the group level, one could report just the 6 best measures. The combination could be 2 anesthesia measures, 2 pathology measures and 2 hospitalist measures. There is no need to cover all specialties. One just needs to report the patients/visits eligible for the chosen measures. For example, measure #32 (Stroke and Stroke Rehabilitation: Discharged on Antithrombotic Therapy) will only apply for patients discharged by the hospitalist.  Please note that there are measures that apply to patients seen by different specialties: for example measure #226  (Tobacco Use: Screening and Cessation Intervention) will apply to all outpatient office visits done by the internists, dermatologists and cardiologists. 
    • The same group level reporting advantages would apply with other MIPS components like Improvement Activities. For example, all 6 members of the practice described above could share on the MIPS points when just one  cardiologist is participating in the systematic anticoagulation program (high weighted Improvement Activity).
  5. It can be easier to report more specific measures that apply to smaller patient populations. For example, dermatologists could report melanoma measures #137, #138 and #224. However, one needs to report a minimum of 20 patients in order to get a score higher than 3.
  6. Please note the reporting frequency of measures like measure #226 (Tobacco Use: Screening and Cessation Intervention) that only need to be reported once per patient per year versus measures like measure #130 (Documentation of Current Medications in the Medical Record) that need to be reported on each eligible visit. For example, measure #226 only needs to be reported once on a patient seen for a total of 7 times by 4 different providers at the group level. Measure #130 will need to be reported 7 times on this case.
  7. Be aware of "easy" measures with which most providers already have high compliance (i.e. high national benchmarks). Medicare calls these measures "topped-out" measures. For example, measure #130 (Documentation of Current Medication in the Medical Record) has the following MIPS scoring:
    • 3 Points 61.27 - 82.11 %
    • 4 Points 82.12 - 91.71 %   - This means that a provider with a performance rate of 90% will only get 4 MIPS points
    • 5 Points 91.72 - 96.86 %   
    • 6 Points 96.87 - 99.30 %
    • 7 Points 99.31 - 99.99 %
    • 10 Points 100 % - This means that if a provider only gets 10 points on this measure if ALL patients had medications documented on ALL visits. If the documentation is not done once during the reporting period, the provider will get 7 points or less instead of 10.
  8. Be aware of choosing measures without benchmarks. Measures without benchmarks can only earn maximum 3 points (unless the measure is a high priority or outcome measure where one could could get one or two additional bonus points).
  9. You can find the MIPS quality measures benchmarks and which measures have no benchmarks or are topped-out on this CMS Excel file.
  10. Example of MIPS quality measures which give 10 points with performances below 100%:
    • #400 Hepatitis C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk >= 20.02%
    • #343 Screening Colonoscopy Adenoma Detection Rate >= 80.33%
    • #39 Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older >= 82.54%
    • #112 Breast Cancer Screening  >= 87.93%
    • #113 Colorectal Cancer Screening >= 88.15%
    • #111 Pneumonia Vaccination Status for Older Adults >= 90.20%
    • #236 Controlling High Blood Pressure >= 91.07%
    • #110 Preventive Care and Screening: Influenza Immunization >= 91.84%
    • #118 Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%) >= 96.00%
    • #5 Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) >= 96.55%
    • #128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan >= 97.34%
    • #7 Coronary Artery Disease (CAD): Beta-Blocker Therapy - Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%) >= 97.92%
    • #317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented >= 98.88%
    • #119 Diabetes: Medical Attention for Nephropathy >= 99.71%
    • #178 Rheumatoid Arthritis (RA): Functional Status Assessment >= 99.72%
    • #122 Adult Kidney Disease: Blood Pressure Management >= 99.75%
  11. Example of inverse MIPS quality measures which give 10 points with performances higher than 0%:
    • #1 Diabetes: Hemoglobin A1c Poor Control <= 10.32%>
    • #164 Coronary Artery Bypass Graft (CABG): Prolonged Intubation <=  1.82%
  12. Examples of measures that are not topped-out and have benchmarks that could be reported by an internist:
    • Measure #1 (Diabetes A1C) - High Priority Measure

      • 3 Points 83.10 - 68.19 %
      • 4 Points 68.18 - 53.14 %
      • 5 Points 53.13 - 40.66 %
      • 6 Points 40.65 - 30.20 %
      • 7 Points 30.19 - 22.74 %  - For example, 30% performance will get the provider 7 points. Please note this is an inverse measure.
      • 8 Points 22.73 - 16.82 %
      • 9 Points 16.81 - 10.33 %
      • 10 Points <= 10.32 %
    • Measure #48 Urinary Incontinence

      • 3 Points 16.31 - 29.03 %
      • 4 Points 29.04 - 42.90 %
      • 5 Points 42.91 - 57.07 %
      • 6 Points 57.08 - 76.52 %
      • 7 Points 76.53 - 89.12 % -  For example, 77% performance will get the provider 7 points.
      • 8 Points 89.13 - 96.91 %
      • 9 Points 96.92 - 99.99 %
      • 10 Points 100 %
    • Measure #112 Breast Cancer Screening

      • 3 Points 14.49 - 24.52 %
      • 4 Points 24.53 - 35.70 %
      • 5 Points 35.71 - 46.01 %
      • 6 Points 46.02 - 55.06 %
      • 7 Points 55.07 - 63.67 % -  For example, 56% performance will get the provider 7 points.
      • 8 Points 63.68 - 74.06 %
      • 9 Points 74.07 - 87.92 %
      • 10 Points 87.93 % -  For example, 88% performance will get the provider 10 points.
    • Measure #236 Controlling High Blood Pressure - Outcome Measure

      • 3 Points 51.00 -58.20 %
      • 4 Points 58.21 - 63.56 %
      • 5 Points 63.57 - 68.27 %
      • 6 Points 68.28 - 72.40 %
      • 7 Points 72.41 - 76.69 % -  For example, 73% performance will get the provider 7 points.
      • 8 Points 76.70 - 82.75 %
      • 9 Points 82.76 - 91.06 %
      • 10 Points 91.07%
  13. Examples of measures that are not topped-out and have benchmarks that could be reported by a cardiologist:
    1. Measure# 5 Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)

          • 3 Points 75.86 - 79.58%
          • 4 Points 79.49 - 82.13 %
          • 5 Points 82.14 - 84.99 %
          • 6 Points 85.00-87.49 %
          • 7 Points 87.50 - 89.99 %  - For example, 88% performance will get the provider 7 points.
          • 8 Points 90.00 - 93.53%
          • 9 Points 93.54 - 96.54 %
          • 10 Points 96.55 %
        • Measure #8 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) Add

          • 3 Points 76.58 - 81.07 %
          • 4 Points 81.08 - 85.57 %
          • 5 Points 85.58 - 88.43 %
          • 6 Points 88.44 - 91.16 %
          • 7 Points 91.17 - 94.28 % -  For example, 92% performance will get the provider 7 points.
          • 8 Points 94.29 - 96..36 %
          • 9 Points 96.37 - 99.99 %
          • 10 Points 100 %
        • Measure #118 Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)

          • 3 Points 71.03 - 74.18 %
          • 4 Points 74.19 - 76.51 %
          • 5 Points 76.52 - 78.94 %
          • 6 Points 78.95 - 81.10%
          • 7 Points 81.11 - 83.99 % -  For example, 82% performance will get the provider 7 points.
          • 8 Points 84.00 - 87.79 %
          • 9 Points 8780 - 95.99 %
          • 10 Points 96.00 %
        • Measure #326 Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy

          • 3 Points 20.00 - 30.18%
          • 4 Points 39.19 - 52.33 %
          • 5 Points 52.34 - 69.56 %
          • 6 Points 69.57 - 76.18 %
          • 7 Points 76.19 - 82.49 % -  For example, 77% performance will get the provider 7 points.
          • 8 Points 82.50 - 94.33 %
          • 9 Points 94.34 - 99.99
          • 10 Points 100.00%
  14. Examples of measures that are not topped-out and have benchmarks that could be reported by an allergist/immunologist:
  • Measure# 317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

    • 3 Points 24.74 - 35.47%
    • 4 Points 35.48 - 47.87%
    • 5 Points 47.88 - 62.14%
    • 6 Points 62.15 - 71.64%
    • 7 Points 71.65-79.36 %  - For example, 72% performance will get the provider 7 points.
    • 8 Points 79.37 - 88.85%
    • 9 Points 88.86 - 98.87%
    • 10 Points 96.55 %
  • Measure #331 Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse) Inverse Measure High Priority Measure

    • 3 Points 89.07 - 82.41%
    • 4 Points 82.40 - 71.44 %
    • 5 Points 71.43 - 46.46 %
    • 6 Points 46.45 - 16.91 %
    • 7 Points 16.90 - 0.60 % -  For example, 16% performance will get the provider 7 points.
    • 8 Points 0.59 - 0.01%
    • 9 Points n/a
    • 10 Points 0%
  • Measure #332 Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use) High Priority Measure

    • 3 Points 44.39 - 47.99 %
    • 4 Points 48.00 - 51.88 %
    • 5 Points 51.89 - 57.57%
    • 6 Points 57.58 - 64.99%
    • 7 Points 65.00 - 72.72% -  For example, 65% performance will get the provider 7 points.
    • 8 Points 72.73 - 95.99 %
    • 9 Points 96.00 - 99.99 %
    • 10 Points 100%
  • Measure #402 Tobacco Use and Help with Quitting Among Adolescents

    • 3 Points 74.10 - 82.15 %
    • 4 Points 81.16 - 87.49 %
    • 5 Points 87.50 - 90.37%
    • 6 Points 90.38 - 92.72 %
    • 7 Points 92.73 - 95.15 % -  For example, 93% performance will get the provider 7 points.
    • 8 Points 95.16 - 97.50 %
    • 9 Points 97.51 - 99.99
    • 10 Points 100%
  1. Examples of measures that are not topped-out and have benchmarks that could be reported by an rheumatologist:
  • Measure# 47 Care Plan - High Priority Measure

    • 3 Points 16.52 - 38.11%
    • 4 Points 38.12 - 59.14%
    • 5 Points 59.15 - 74.99%
    • 6 Points 75.00 - 88.71%
    • 7 Points 88.72 - 96.29 %  - For example, an 89% performance will get the provider 7 points.
    • 8 Points 96.30 - 99.17%
    • 9 Points 99.18 - 99.99%
    • 10 Points 100%
  • Measure #178 Rheumatoid Arthritis (RA): Functional Status Assessment

    • 3 Points 27.99 - 45.95%
    • 4 Points 45.96 - 64.17 %
    • 5 Points 64.18 - 74.46 %
    • 6 Points 7.47 - 81.36 %
    • 7 Points 81.37 - 87.82% -  For example, 82% performance will get the provider 7 points.
    • 8 Points 87.83 - 92.34%
    • 9 Points 92.35 - 99.71
    • 10 Points 100%
  • Measure #317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

    • 3 Points 24.74 - 35.47 %
    • 4 Points 35.48 - 47.87 %
    • 5 Points 47.88 - 62.14%
    • 6 Points 62.15 - 71.64%
    • 7 Points 71.65 - 79.36% -  For example, 72% performance will get the provider 7 points.
    • 8 Points 79.37 - 88.85 %
    • 9 Points 88.86 - 98.87 %
    • 10 Points 98.88%

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