The Clock is Ticking on Reporting MIPS: How to Choose Quality Measures

Posted on November 12, 2020

The clock is ticking for clinicians and groups who want to report MIPS. MDinteractive can report all available registry and EHR MIPS Quality measures and is here to help, whether you have been collecting data throughout the year or are just getting started. In this article we explain how to choose your Quality measures, and the benefits of using a registry like MDinteractive. With the end of the 2020 performance year getting closer, there’s still time to choose measures to report and start gathering your data.

The Basics

The Quality performance category is worth the most of the 4 performance categories, counting towards 45% of your final MIPS score. If fully participating in this category, you should select 6 Quality measures (1 being an Outcome or High Priority measure), or a specialty measure set. Each measure is reported on at least 70% of eligible cases for all insurance types, including Medicare and non-Medicare patients for the entire year. Unlike the Promoting Interoperability and Improvement Activities categories which require a minimum of a 90-day reporting period, Quality has a 12-month reporting period (January 1, 2020 through December 31, 2020).

The Quality category weight of 45% can change based on Special Statuses, reweighting of other performance categories or participating in an Alternative Payment Model (APM).

Choosing Your Quality Measures

The advantage of using a registry like MDinteractive is that you have more measures to choose from. All 2020 MIPS Clinical Quality Measures (CQMs) and electronic Clinical Quality Measures (eCQMs) can be reported with MDinteractive. We understand the decision on which measures to report can be overwhelming, so we have outlined a few key strategies to consider as you select your measures:

Are the measures appropriate for your practice?

Choose quality measures that best fit your practice, including the type of care you provide and the clinical conditions you typically treat. The CMS criteria for each measure will include a description of what is being measured and which patients would be eligible based on any age, diagnosis and billing code requirements (e.g., the “denominator” section of the measure). MDinteractive makes it easy:

Does combining registry and EHR measures make sense?

CMS provides flexibility to report quality measures through multiple submission methods which can help improve MIPS scores and increase Medicare incentive payments. Since EHR measures are limited, this can be a good strategy for clinicians who want to report measures more relevant to their specialty. We explore the advantages of combining registry and EHR measures in this article.

Is the measure “topped-out”?

Quality measures have points available at different performance levels and many have changed this year.  Some measures have 10 points available while others are capped at 7 points.  Topped-out measures can make it more challenging to achieve the maximum number of points under the Quality category. A topped-out measure means that the national median performance rate is so high that there is no meaningful difference in performance between clinicians.

As you choose measures to report, it’s important to consider if any are topped-out and whether reporting less popular measures would allow you to achieve a higher score.

Current benchmarks and points awarded for the 2020 measures can be found here.

Is your eligible population too large or too small?

Since you are required to report at least 70% of eligible cases for each Quality measure, this could mean a lot of data for certain measures that apply to a broad group of patients. Selecting measures with a defined demographic could result in a more manageable eligible population to report. Some measures are only applicable to patients with certain diagnosis (e.g., #6 Coronary Artery Disease (CAD): Antiplatelet Therapy) versus other measures that apply to a larger patient population (e.g., #226 Tobacco Use).

Additionally, consider whether you have a sufficient number of eligible patients to report for a measure. If you have less than 20 eligible patients for a measure, it would only receive 3 MIPS points.

What happens if you don’t have 6 measures to report?

If you or your practice submits data on fewer than 6 quality measures, or fails to submit an Outcome or High Priority measure, CMS will conduct an eligibility measure applicability (EMA) process to identify clinically-related measures you could have submitted. The EMA analysis applies only if you submit data through claims or a qualified registry, and if you submit less than the required quality measures for a program year. More information about the EMA process can be found  here.

How Are Quality Measures Scored

CMS will score your top 6 Quality measures, including at least 1 Outcome or High Priority measure. It will select the highest scoring Outcome measure first (or the highest scoring High Priority measure if an Outcome measure is not available), then the next 5 highest scoring measures.

Measures can generally earn between 3 and 10 points (based on your performance) if the measure:

Meets the data completeness criteria (at least 70% of eligible cases reported for the year)

Has a national benchmarkMeets the case minimum requirements (20 or more patients reported)

There are some exceptions to the scoring methodology:

Measures that meet data completeness, but have less than 20 patients reported or no benchmark*, would receive 3 points.

If measures don’t meet data completeness, they would receive 0 points for large practices (16 or more in the TIN) or 3 points for small practices (15 or less in the TIN).

Scores for extremely topped-out measures are capped at 7 points.

*Note that measures without a benchmark could receive more points at a later date if CMS collects sufficient data during the performance year to establish a benchmark.

Bonus points can be earned in some cases:

*Reporting 2 or more Outcome or High Priority measures (beyond the required one), will result in additional points for those measures (capped at 10%): 2 points for each additional Outcome measure and 1 point for each additional High Priority measure.

End-to-End Electronic Reporting (ETE) reporting would result in 1 bonus point per measure (capped at 10%). End-to-end data must originate from a Certified EHR and can’t be manually modified.Small practices will receive 6 bonus points added to the numerator of their Quality score when reporting this category.

You can earn up to 10 additional percentage points on your Quality score if your 2020 performance has improved as compared to 2019.

*A quality measure must have a performance of greater than 0, and meet data completeness and case minimum requirements, to be eligible for the bonus points.

Collecting Your Data

Collecting a year’s worth of data may seem daunting, but one of the benefits of using MDinteractive is that we offer several solutions to make gathering your data and submitting it to our registry as simple as possible. You have flexibility to choose an option that best fits your needs and unique circumstances:

  • Manual Data Entry - Our easy-to-use software allows you to create patient records directly in your MDinteractive account.
  • MDinteractive Templates - After selecting the measures you plan to report, you can download a template for each measure in your MDinteractive account to track your patient data on a spreadsheet. These templates are populated by your team and re-uploaded to your MDinteractive account for processing.
  • EHR Files - If your EHR is programmed to calculate performance on Quality measures, we can use your EHR reports to process your Quality data. There are several forms of EHR generated files that we can accept, such as QRDA, CSV,  Excel, HTML, and JSON.
  • Billing Files - We can accept files that you generate from your billing software as long as they have the necessary codes.

Not sure if your data is in a format we can accept? Upload a test file to your MDinteractive account and we will review your data and provide feedback.

Getting Started

As the end of the 2020 performance period draws near, now is a good time to identify which Quality measures you plan to report if you haven’t done so already and develop a plan for gathering your data. The Quality category is worth up to 45 points, so it is a large portion of your total MIPS score. All available registry and EHR MIPS Quality measures can be reported with our registry, making it easier to find measures you can report. MDinteractive provides many resources to help you choose your measures and collect your data. Our MIPS specialists are also available to help you with your MIPS reporting plans and answer any questions you have along the way.

MACRA 2020 MIPS Reporting Quality Measures Quality Scores Registry Reporting

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