Quality is one of four performance categories under the Merit-based Incentive Payment System (MIPS). For 2017, to fully participate in the Quality performance category, you or your group need to report on:
- Six quality measures, one of which is required to be an outcome measure, if available. If an outcome measure is not available, then you have to submit a high priority measure. You or your group would also have to meet the data completeness requirement (at least 50% of possible data submitted) for each measure submitted.
- A complete specialty measure set. All of the measures in a specialty set (measures specifically for specialties such as Anesthesiology, Cardiology, and Ophthalmology) will be assessed when less than 50% of possible data are submitted.
If you or your group submits data on fewer than six quality measures, CMS will conduct an eligible measure applicability (EMA) process to identify clinically related measures you could have submitted. The EMA analysis applies only if you submit data through claims or a qualified registry, and if you submit less than the required quality measures for a program year.
The EMA process:
- Uses a clinical relations test to see if you could have submitted more measures, including outcome and high priority measures
- Adjusts the scoring to accurately reflect how the clinical relations test affected your or your group’s performance
How does the EMA process tell if another measure was available?
There’s a two-step process used to see if more quality measures applied to you or your group. This process is based on clinical relationships related to the measure(s) submitted:
Step 1: Clinical Relation Test sees if there are more clinically related quality measures based on the one to five quality measures you submitted.
Clinical Relation and Outcome/High Priority Test if none of the six or more quality measures you submitted are an outcome or high priority measure, this test sees if any are clinically related to an outcome or high priority.
Step 2: Minimum Threshold Test looks at the Medicare claims you submitted to see if there are at least 20 denominator eligible instances for any extra measures found in Step 1. This EMA step only applies to the claims data you submitted. This test is separate from the MIPS requirement that you need 50% data completeness to get a benchmark performance calculation in the 2017 performance year.
To learn more about the EMA analysis and how it affects your quality performance calculation and score, see:
- MIPS Quality Performance Category EMA Fact Sheet
- 2017 EMA for Registry Data Submission of Individual Quality Measures
For example, a dermatologist reports all the Melanoma Care clinically related quality measures (137, 138, 224) through a registry and scores 20 points. Those 20 points are usually compared with a quality score target of 60 based on the required 6 measures (i.e. 10 points x 6 measures = 60 points). However, EMA looks to see if any of the measures submitted by the dermatologist apply to the clinical relationships mapped in EMA clinical quality measure relationships. EMA finds that the dermatologist couldn’t have submitted any additional quality measures. The quality performance category score target is then lowered from 60 measure points to 30 measure points so the MIPS score for the dermatologist is not negatively impacted.
Please note: You or your group should submit all measures that apply to your scope of practice and not limit your submission to clinically related measures.