For quality measures, CMS uses data that was reported in previous years to create performance benchmarks.
Each quality measure is converted into a 10 point scoring system. Performance on quality measures is broken down into 10 "deciles", with each decile having a value of between 1 and 10 points. A clinician or group's performance on a quality measure will be compared to the performance levels in the national deciles. Registry measures are compared to registry benchmarks.
A measure can be reliably scored against a benchmark if...
A national benchmark exists
The sufficient case volume has been met (20 or more cases in the report)
At least 60% of possible data for a measure is submitted (data completeness)
Note: If a measure cannot be scored against a benchmark or no benchmark exists, it will automatically receive 3 points as long as it is complete.