MIPS measures with multiple performance rates

There are several MIPS measures that require the collection and submission of data for multiple populations. This means that there can be multiple performance rates associated with a single measure. Accordingly, these are often referred to as "multi-performance rate measures".
Historical benchmarks for these measures were created based on the "overall performance rate". When you are scored on a multi-performance rate measure, CMS will compare the "overall performance rate" of your submitted measure to the measure's benchmark which is also based on the "overall performance rate". 

An overall performance rate may be determined in one of three ways:

  • Weighted Average (Example: Measure 007)
 
DENOMINATOR (SUBMISSION CRITERIA 1): All patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have a current or prior LVEF < 40%
Performance Met (Performance NUMERATOR #1): Beta-blocker therapy prescribed or currently being taken
DENOMINATOR (SUBMISSION CRITERIA 2): All patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have prior (within the past 3 years) MI
Performance Met (Performance NUMERATOR #2): Beta-blocker therapy prescribed or currently being taken
Example
Clinician collects and submits the following data through a Qualified Registry for Measure 007:
 
20 patients in Denominator 1
18 patients in Numerator 1
30 patients in Denominator 2
24 patients in Numerator 2
No patients qualified for a denominator exception
 
Performance Rate 1: 18/20 = .900 or 90.0%
Performance Rate 2: 24/30 = .800 or 80.0%
The system calculates the overall performance rate using the numerator and denominator values

Weighted Average Calculation = [sum of numerator values] divided by [sum of denominator values]
Overall Performance Rate = (18 + 24)/(20 + 30) = .84 or 84%
  • Simple Average (Example: Measure 009)
 
DENOMINATOR (1 and 2): Patients 18 years of age and older with a visit during the measurement period who were dispensed antidepressant medications in the time within 270 days (9 months) prior to the measurement period through the first 90 days (3 months) of the measurement period, and were diagnosed with major depression 60 days prior to, or 60 days after the dispensing event
NUMERATOR 1: Patients who have received antidepressant medication for at least 84 days (12 weeks) of continuous treatment during the 114-day period following the Index Prescription Start Date
NUMERATOR 2: Patients who have received antidepressant medications for at least 180 days (6 months) of continuous treatment during the 231-day period following the Index Prescription Start Date
Example
Clinician collects and submits the following data via certified EHR technology for Measure 009 (CMS 128v6):
 
20 patients in Denominator (1 and 2)
18 patients in Numerator 1
15 patients in Numerator 2
No patients qualified for a denominator exception
 
The system calculates the overall performance rate using the performance rates calculated for rates 1 and 2

Simple Average = [sum of performance rates] divided by [the number of performance rates]
 
Performance Rate 1: 18/20 = .900 or 90.0%
Performance Rate 2: 15/20 = .750 or 75.0%
 
Overall Performance Rate = (.900 + .750)/(2) = .825 or 82.5%
  • Specified Performance Rate (Example: Measure 046 - 3rd Performance Rate)
DENOMINATOR 1: Patients 18-64 years of age seen within 30 days in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care following discharge from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility)
DENOMINATOR 2: Patients aged 65 years and older on date of encounter seen within 30 days in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care following discharge from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility)
DENOMINATOR 3: All Patients 18 years of age and older seen within 30 days in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care following discharge from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility)
Performance Met (Performance NUMERATOR 1, 2, and 3) Discharge medications reconciled with the current medication list in outpatient medical record [for each distinct patient population]
Example 
Clinician collects and submits the following data through a Qualified Registry for Measure 046:
60 patients in Denominator 1
40 patients in Numerator 1
40 patients in Denominator 2
30 patients in Numerator 2
100 patients in Denominator 3
70 patients in Numerator 3
No patients qualified for a denominator exception.
The system determines the overall performance rate by calculating the performance rates for the measure strata or sub-components
Performance Rate 1: 40/60 = .667 or 66.7%
Performance Rate 2: 30/40 = .750 or 75.0%
Performance Rate 3: 70/100 = .700 or 70.0%

Overall Performance Rate = Performance Rate 3 = 70.0%

 

Measure TitleQuality NumberOverall Performance Rate 2018Number of Performance Rates 2018
Coronary Artery Disease (CAD): Beta-Blocker Therapy - Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%)007Weighted Average2
Anti-Depressant Medication Management009Simple Average2
Medication Reconciliation Post-Discharge0463rd Performance Rate3
Adult Kidney Disease: Blood Pressure Management1223rd Performance Rate3
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention2262nd Performance Rate3
Use of High-Risk Medications in the Elderly2381st Performance Rate2
Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents239Simple Average3
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment305Simple Average2
HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate348Weighted Average2
ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication366Simple Average2
Depression Utilization of the PHQ-9 Tool371Weighted Average3
Follow-up After Hospitalization for Mental Illness (FUH)3912nd Performance Rate2
HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation3925th Performance Rate5
Immunizations for Adolescents3944th Performance Rate4
Optimal Asthma Control3981st Performance Rate7
Average Change in Back Pain following Lumbar Discectomy / Laminotomy4592nd Performance Rate2
Average Change in Back Pain following Lumbar Fusion4602nd Performance Rate2
Average Change in Leg Pain following Lumbar Discectomy and/or Laminotomy4612nd Performance Rate2
Developmental Screening in the First Three Years of Life4674th Performance Rate4

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