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MIPS Eligible Measure Applicability (EMA)

Quality is one of four performance categories under the Merit-based Incentive Payment System (MIPS). For 2020, 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.

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.

Tips on how to choose Quality measures can be found here:

  • Start by reviewing the suggestions by specialty available on our website.  Note that CMS has identified “Specialty Measures Sets” for the majority of specialties. Suggestions for your specialty can be found here.  
  • You can access our MIPS planning tool within our software by logging into your account, setting up your dashboard with NPI/TIN and clicking on Add/Edit MIPS Plans. After you indicate the categories you will be reporting and clicking “Next”, you will be able to choose from a list of applicable measures or use the filters to narrow down your choices. Note that only measures where you have claims history matching the criteria will appear in this list.  Please contact MDinteractive if you don’t see a measure available on your list.
  • Consider the following factors 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;
    • Only choosing/reporting measures where you have eligible encounters, meaning encounters where the coding on the claims matches the denominator criteria for the measure.  The documentation for all measures can be found on this link: 2020 Quality Measures.
  • At least 1 of the measures you choose (out of a total of 6) must be designated as either Outcome, or if no applicable Outcome, another High Priority measure.  If a measure with either of these designations is not included in your reporting, CMS will only score 5 out of your 6 measures. The following is an explanation of the measure “types”:
    • Process - Process measures show what doctors and other clinicians do to maintain or improve health, either for healthy people or those diagnosed with a given condition or disease.  These measures usually reflect generally accepted recommendations for clinical practice.  Process measures can tell consumers about medical care they should receive for a given condition or disease, and can help improve health outcomes.
    • Outcome - Outcome measures show how a health care service or intervention influences the health status of patients. Examples: The % of patients who died because of surgery or the rate of surgical complications or hospital acquired infections.  Outcome measures are the result of many factors, some of which may be out of a clinician's control. An Outcome Measure is also classified as High Priority.  CMS asks for an Outcome Measure to be reported as part of the 6 total measures (if one is applicable).
    • High Priority - High priority measures include the following categories of measures:  Outcome, Appropriate Use, Patient Experience, Patient Safety, Efficiency measures, Care coordination. If an Outcome measure (see above) is not applicable, a measure designated as just “high priority” will suffice. 
  • Because you will need to report at least 70% of the patients/visits eligible for a measure (ALL insurances, Medicare and not Medicare) you could choose to select measure(s) with a more defined demographic (meaning that the denominator criteria is limited by ICD-10, age, gender, etc. vs. all eligible patient visits) in order to create a manageable size report.  Note though that measures must be complete and contain at least 20 denominator eligible cases in order to be scored against national benchmarks.
  • Choosing to report Quality measures as a group (if more than two in the practice) might be a more efficient way to report.  Here is an example of how this would work:
    • Multi-specialty practice: Let's imagine a practice with 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 (6 measures per provider). A group would be able to choose 6 measures that would “cover” the entire practice.   For example, the measure selection could include 2 anesthesia measures, 2 pathology measures and 2 hospitalist measures. There is no need to choose measures that cover all specialties. One just needs to report the patients/visits eligible for the chosen measures. For example, Measure #137  (Melanoma: Continuity of Care – Recall System) will only apply for patients seen by the dermatologist. 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. 
  • 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.
  • Consider the reporting frequency of measures such as 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 eligible encounters. Measure #130 will need to be reported 7 times in this example.

Understanding Benchmarks/Scoring when Choosing Your Quality Measures:

  • Be aware of measures which already have high compliance. Medicare calls these "topped-out" measures. For example, Measure #130 (Documentation of Current Medication in the Medical Record) has the following MIPS scoring. Note that a performance score of 100% will only achieve 7 (vs. 10) MIPS points. MIPS 2020 benchmarks for all measures can be found here 
    • 3 Points 3.07 - 43.67 %
    • 4 Points 43.68 - 94.64 %  
    • 5 Points 94.65 - 99.68 %   
    • 6 Points 99.69 - 99.99 %
    • 7 Points 100%
  • Take into consideration that some measures do not currently have benchmarks. As a result, these measures will initially achieve only 3 points - even if reported completely. 
  • You can find the MIPS quality measures benchmarks and which measures have no benchmarks or are topped-out here: 2020 Quality Benchmarks.
  • The following is a list of measures, within a selection of specialties, that can achieve at least 8 points for less than 100% performance or 0% performance for inverse measures (*denotes a measure that can only be reported if data calculated by EHR):
    • Internal Medicine 
      • Measure 1 Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)
      • Measure 39 Screening for Osteoporosis for Women Aged 65-85 Years of Age
      • Measure 110 Preventive Care and Screening: Influenza Immunization
      • Measure 111 Pneumococcal Vaccination Status for Older Adults
      • Measure 236 Controlling High Blood Pressure
      • Measure 243 Cardiac Rehabilitation Patient Referral from an Outpatient Setting
      • Measure 305* Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
      • Measure 309* Cervical Cancer Screening
      • Measure 318* Falls: Screening for Future Fall Risk
      • Measure 331 Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)
      • Measure 377* Functional Status Assessments for Congestive Heart Failure
      • Measure 400 One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk
      • Measure 418 Osteoporosis Management in Women Who Had a Fracture
      • Measure 441 Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)
    • Cardiology
      • 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%)
      • Measure 236 Controlling High Blood Pressure
      • Measure 243 Cardiac Rehabilitation Patient Referral from an Outpatient Setting
      • Measure 441 Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)
    • Allergist/Immunology
      • Measure 110 Preventive Care and Screening: Influenza Immunization
      • Measure 111 Pneumococcal Vaccination Status for Older Adults
    • Rheumatology
      • Measure 39 Screening for Osteoporosis for Women Aged 65-85 Years of Age
      • Measure 110 Preventive Care and Screening: Influenza Immunization
      • Measure 111 Pneumococcal Vaccination Status for Older Adults
      • Measure 236 Controlling High Blood Pressure

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.

OR

  • 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:

Note:  2020 MIPS EMA for MIPS CQMs are coming soon.  Please use 2019 link for reference only.

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.

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