Measure with Less than Optimal Performance in a 90-Day Submission Period

Most quality measures can be used for 90-day performance period. There are some measures, though, that by design, are hard to align with a 90-day performance period and some are not feasible for certain timeframes in which the measure may be analyzed.

For example, some measures are based on observation periods after an event such as a surgery or discharge from acute care. MIPS Quality ID: 191, CMS133: Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery, has a 90-day look forward period of observation after the denominator qualifying event of cataract surgery. This is accommodated in the measure specification by including only cataract surgeries in the first 270 days of the year (January 1 through September 30) allowing for follow-up assessment within 90- days post-surgery (October 1 through December 31) before the end of the calendar year. Therefore, a 90-day performance period that included dates in October, November, or December would not be feasible for submission purposes and an alternative to the 4th quarter 90-day submission period should be selected for this measure.

There are 43 quality measures that may not be ideal if implemented within the 90-day performance period; the limitations and rationale associated with these measures are indicated in the table, located in the appendix of this CMS document.

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