MIPS Eligible Measure Applicability (EMA)

Quality is one of four performance categories under the Merit-based Incentive Payment System (MIPS). To fully participate in the Quality performance category, you or your group need to report on:

  • Six quality measuresone 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 70% of possible data submitted) for each measure submitted.
  • Submit a complete specialty measure set if the specialty measure set contains less than 6 measures.

Eligible clinicians can report less than 6 measures, or without an Outcome/High Priority Measure and be eligible for the full Quality incentive through the Eligible Measures Applicability (EMA) Process. 

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 doesn'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

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 clinician reporting the Anesthesiology clinically related quality measures (404, 424, 430 and 463) through a registry could score up to 40 points. Those 40 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). Under EMA, the quality performance category score is then re-weighted from 40 points to 60 points so the MIPS score for the clinician is not negatively impacted. 

If the clinician also have zero eligible instances for measure 463 in the  EMA cluster, measure #463 will be submitted to 0/0 and the 3 remaining  anesthesiology measures will be re-weighted to 60 MIPS points.

These are the 2022 sets of MIPS registry measures that get the score adjusted by EMA:

Anesthesiology Care:

  • #404 Anesthesiology Smoking Abstinence
  • #424 Perioperative Temperature Management
  • #430 Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy
  • #463 Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics)

CABG Care

  • #167 Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure
  • #168 Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration
  • #445 Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)

Cardiac Stress Imaging

  • #322 Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients
  • #323 Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI)
  • #324 Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients

Cataract Care

  • #191 Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery
  • #303 Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery
  • #304 Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery
  • #389 Cataract Surgery: Difference Between Planned and Final Refraction

Computed Tomography

  • #360 Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies
  • #364 Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines
  • #405 Appropriate Follow-up Imaging for Incidental Abdominal Lesions
  • #406 Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients
  • #436 Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques

Diagnostic Imaging

  • #145 Radiology: Exposure Dose Indices or Exposure Time and Number of Images Reported for Procedures Using Fluoroscopy
  • #147 Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy

Endoscopy and Polyp Surveillance

  • #185 Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use
  • #320 Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients
  • #425 Photodocumentation of Cecal Intubation
  • #439 Age Appropriate Screening Colonoscopy

Pathology

  • 249: Barrett’s Esophagus 250: Radical Prostatectomy Pathology Reporting
  • #395 Lung Cancer Reporting (Biopsy/Cytology Specimens)
  • #396 Lung Cancer Reporting (Resection Specimens)
  • #397 Melanoma Reporting

Pathology – Skin Cancer

  • #397 Melanoma Reporting
  • #440 Skin Cancer: Biopsy Reporting Time – Pathologist to Clinician

Surgical Care

  • #355 Unplanned Reoperation within the 30 Day Postoperative Period
  • #357 Surgical Site Infection (SSI)
  • #358 Patient-Centered Surgical Risk Assessment and Communication

Internal Eye Care

  • #141 Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care
  • #384 Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery
  • #385 Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery

Interventional Radiology

  • #145 Radiology: Exposure Dose Indices or Exposure Time and Number of Images Reported for Procedures Using Fluoroscopy
  • #409 Clinical Outcome Post Endovascular Stroke Treatment
  • #413 Door to Puncture Time for Endovascular Stroke Treatment
  • #465 Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries

There are also Specialty Measure Sets with Fewer than 6 Measures that get quality re-weighted:

    Electrophysiology

    • #392 Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation
    • #393 Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision

    Hospitalists

    • #5 Heart Failure (HF): AngiotensinConverting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
    • #8 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
    • #47 Advance Care Plan
    • #76 Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections
    • #130 Documentation of Current Medications in the Medical Record

    Podiatry

    • #126 Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation
    • #127 Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear
    • #128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
    • #155 Falls: Plan of Care
    • #226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

    Radiation Oncology

    • #102 Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients
    • #143 Oncology: Medical and Radiation – Pain Intensity Quantified
    • #144 Oncology: Medical and Radiation – Plan of Care for Pain

    Speech Language Pathology

    • #130 Documentation of Current Medications in the Medical Record
    • #134 Preventive Care and Screening: Screening for Depression and Follow-Up Plan
    • #181 Elder Maltreatment Screen and Follow-Up Plan
    • #182 Functional Outcome Assessment
    • #226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

    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.

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