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 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 (report 100% of eligible encounters and provide answers for at least 75%) 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.  The maximum points available for each measure with a perfect performance rate (based on CMS published benchmarks) are shown in parenthesis.  Measures without max points currently do not have historical benchmarks. Scores, based on performance for non-benchmarked measures, will be calculated post submission.

These are the 2024 sets of MIPS registry measures that get the score adjusted by EMA:

Anesthesiology Care

CABG Care

Cardiac Stress Imaging

Cataract Care

Computed Tomography

Diagnostic Imaging

Endoscopy and Polyp Surveillance

Interventional Radiology

Pathology 1

Pathology 2

Pathology – Skin Cancer

Surgical Care

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

    Anesthesiology

    Electrophysiology

    Hospitalists

    Radiation Oncology

    Please note: You should submit all quality measures that apply to your scope of practice and not limit your submission to those measures contained within the clinical topic. The EMA process was established to support clinicians and groups who may not have 6 quality measures available for, and applicable, to their practice.

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