Quality is one of four performance categories under the Merit-based Incentive Payment System (MIPS). For 2019, 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 60% of possible data submitted) for each measure submitted.
- Submit a complete specialty measure set if the specialty measure set contains less than 6 measures.
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.
Which collection types are eligible for EMA?
The EMA process is only applied to the following collection types :
- MIPS clinical quality measures (MIPS CQMs) (formerly referred to as “Registry measures”);
- Medicare Part B claims measures (only available for small practices)
CMS doen’t apply the EMA process to Qualified Clinical Data Registry (QCDR) measures or eCQMs collected in Certified Electronic Health Record Technology (CEHRT) because the clinical relationship pattern analysis (previously known as cluster analysis) either doesn’t apply or can’t be done within the current QCDR or CEHRT certification requirements.
If you submit any QCDR measures or eCQMs, alone or in combination with Medicare Part B claims measures or MIPS CQMs, you are expected to submit 6 quality measures.
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?
For measures submitted by Qualiffied Registries, the EMA process is based on clinical relationships related to the measure(s) submitted:
- 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 sees if none of the six or more quality measures you submitted are an outcome or high priority measure, are any clinically related to an outcome or high priority.
To learn more about the EMA analysis and how it affects your quality performance calculation and score, see:
EMA’s practical effect when you submit less than 6 quality measures:
For example, a dermatologist reports all the Melanoma Care clinically related quality measures (137 and 138) 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 re-weighted from 20 measure points to 60 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.