We have almost reached the halfway mark for the 2022 MIPS performance year, so clinicians should be actively collecting and reporting data on their Quality measures. Each year the Centers for Medicare and Medicaid Services (CMS) updates the list of Quality measures eligible clinicians and groups can report under the MIPS program. Some measures get added to or deleted from the inventory, while other measures go through substantial revisions. This article summarizes important changes to the 2022 Quality Measures so that clinicians can make sure their data collection and reporting is on the right track.
MIPS Quality Reporting
Clinicians participating in the traditional MIPS program must annually collect and report data on Quality measures relevant to their practice. The Quality performance category of MIPS measures a clinician’s performance on health care processes, outcomes, and patient experiences of their care. It is worth 30% of the total MIPS score in 2022 (40% for small practices that don’t report the Promoting Interoperability category), so maximizing the Quality score will be an important factor in meeting the higher minimum performance threshold of 75 MIPS points this year.
As in previous years, clinicians must select at least 6 Quality measures (including one outcome or high priority measure), or one specialty measure set, and report each measure on at least 70% of eligible patients regardless of insurance type. The Quality category has a 12-month performance period (January 1 – December 31, 2022), so clinicians must collect data for each measure for the full calendar year.
In certain cases, clinicians can report less than 6 measures and be eligible for the full Quality incentive through the Eligible Measures Applicability (EMA) Process. Under EMA, for example, an anesthesiologist may only need to report 4 quality measures (404, 424, 430 and 463) with a registry.
Also some specialty measure sets require reporting less than 6 measures (Electrophysiology, Hospitalists, Radiation Oncology, and Speech Language Pathology). For example, a hospitalist only needs to report 5 measures (5, 8, 76, 47 and 130).
MIPS Quality Measure Changes in 2022
There are 200 MIPS Quality measures available to report for the 2022 performance period. CMS publishes changes to the Quality measure inventory at the start of each new performance year. Updates to the list of Quality measures can be found on MDinteractive’s website here.
2022 New Quality Measures
There are four new quality measures that have been added to the MIPS program in 2022 (including one new administrative claims-based measure).
*Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions is also a new claims-based measure in 2022.
2022 Removed Quality Measures
CMS removed 13 MIPS quality measures which can no longer be reported.
|2022 Retired Quality Measures|
|#21 Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second-Generation Cephalosporin|
|#23 Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)|
|#44 Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery|
|#67 Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow|
|#70 Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry|
|#154 Falls: Risk Assessment|
|#195 Radiology: Stenosis Measurement in Carotid Imaging Reports|
|#225 Radiology: Reminder System for Screening Mammograms|
|#337 Psoriasis: Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis on a Biological Immune Response Modifier|
|#342 Pain Brought Under Control Within 48 Hours|
|#429 Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy|
|#434 Proportion of Patients Sustaining a Ureter Injury at the Time of Pelvic Organ Prolapse Repair|
|#444 Medication Management for People with Asthma|
Measures With Substantive Changes
Each quality measure has its own specifications which can also change from year-to-year. The individual measure specifications are detailed descriptions of the quality measures and include information on the eligible population (denominator) and the defined quality actions expected for each patient, procedure, or other unit of measurement for the eligible population (numerator).
There are 87 existing MIPS quality measures that have been modified for the current performance year. Clinicians should carefully review the measure specifications for each measure they are reporting. We have highlighted a few examples of measure changes below for some commonly reported measures.
- #111: Pneumococcal Vaccination Status for Older Adults
- The age range for this measure increased from 65 to 66.
- An exception was added for not receiving the vaccine for medical reasons.
- The measure provides credit for adults 66 years of age and older who have received the PPSV23 vaccine on or after the patient’s 60th birthday. Previously, receipt or report of receipt of any pneumonia vaccine met this measure.
- #116: Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis
- Removed Ticarcillin clavulanate and Erythromycin sulfisoxazole from the list of antibiotic medications
- #238: Use of High-Risk Medications in Older Adults
- There is a new, distinct class of high-risk medications containing antipsychotics and benzodiazepines.
- The measure will have 2 performance rates in 2022: 1. Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class. 2. Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class (antipsychotics or benzodiazepines), except for appropriate diagnoses.
- The measure also has new quality action responses:
- At least two orders for high-risk medications from the same drug class NOT ordered
- At least two orders for high-risk medications from the same drug class
- Two or more antipsychotic prescriptions ordered for patients with the appropriate diagnosis
- Two or more benzodiazepine prescriptions ordered for patients with the appropriate diagnosis
- Two or more antipsychotic prescriptions ordered
- Two or more benzodiazepine prescriptions ordered
- #326: Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy
- CMS has decided to suppress measure #326 for the 2022 Performance Period due to a typographical error in the measure specifications which led to an incorrect denominator exception. This measure will not be scored, but the final quality score will be re-weighted without harming the clinician submitting this measure.
- #335: Maternity Care: Elective Delivery (Without Medical Indication) at < 39 Weeks (Overuse)
- This measure is now an inverse measure. A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Submitting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care.
- #350: Total Knee or Hip Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy
- This measure now includes Hip Replacements.
- #351: Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation
- This measure now includes Hip Replacements.
- #400: One-Time Screening for Hepatitis C Virus (HCV) for all Patients
- This measure now applies to all patients aged 18 years and older and not solely to high-risk populations.
2022 Quality Measure Scoring
A clinician’s performance on a measure is compared to a national benchmark to determine how many points the measure earns. Clinicians and groups may generally earn between 3* and 10** points for each quality measure if the following criteria are met:
- Data completeness threshold: The measure is reported on at least 70% of eligible patients, regardless of insurance type, for the full calendar year; AND
- Case minimum: The measure is reported on at least 20 cases; AND
- Benchmark: The measure has an historic performance year benchmark.
* Large practices will earn 0 points on a measure (or 3 points for those in small practices) that do not meet the data completeness criteria, regardless of case minimum or benchmark.
**Some measures that CMS has designated as “topped out” due to historically high performance rates are capped at 7 points.
CMS adopted some changes to quality performance scoring for the 2022 performance year, including:
- A 7-point floor for new measures in their first year in MIPS.
- A 5-point floor for new measures in their second year in MIPS.
- Bonus points are no longer available for reporting additional outcome and high priority measures or measures that meet end-to-end electronic reporting criteria. A bonus of six points will still be added to the Quality performance category score for small practice clinicians who submit at least 1 measure, either individually or as a group (this bonus isn't added to clinicians or groups who are scored under facility-based scoring).
Each measure has its own benchmark that is specific to the collection type: Qualified Clinical Data Registry (QCDR) measures, MIPS Clinical Quality Measures (MIPS CQMs)*, electronic CQMs (eCQMs), CMS Web Interface measures, the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS survey, and Part B Claims measures. For quality measures with no historical benchmark, CMS will calculate benchmarks based on 2022 data. If no benchmark can be calculated, the measure can only earn a maximum of 3 points (as long as data completeness criteria has been met). A benchmark may be calculated post submission if CMS collects sufficient data during the performance period.
There are several 2022 Quality measures with no historic benchmark. Clinicians should closely examine the measure benchmarks to understand the scoring implications for the measures they plan to report. All 2022 measure benchmarks can be found here.
Start Reporting Now
Clinicians should carefully review the list of 2022 Quality measures to make sure their measures are still available to report in 2022 and to understand any changes to measure specifications that could impact their data collection and reporting workflow. Since the performance year is almost half over, clinicians should already be collecting and reporting data, or starting this process soon. It’s more important than ever to monitor performance and MIPS scores throughout the year since the 2022 minimum reporting requirements will be harder to meet.
2022 MIPS Quality Measures 2022 Benchmarks 2022 MIPS Measure Changes
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