This content was excerpted from EyeNet’s MIPS Manual 2017.
You are eligible for the performance score only if you achieved the base score.
Most performance score measures are optional. However, some performance score measures are also required for the base score and are therefore mandatory.
Report either 2-7 or 3-9 performance score measures, depending on which measure set you use. The 2017 ACI transition measure set contains 7 performance score measures—2 mandatory and 5 optional (see “2017 ACI Transition Measures” or download Table 11 [PDF]). The ACI measure set contains 9 performance score measures—3 mandatory and 6 optional (see “ACI Measures” or download Table 12 [PDF]).
Your score for a performance score measure will depend on your performance rate. Most performance score measures are assigned a score of 0%-10% using decile-based scoring: You get a score of 1% if your performance rate is in the first decile (1%-10%), 2% if it is in the second decile (11%-20%), etc. (see Table 10, below). If your performance rate falls between deciles, it is rounded off to the nearest integer; if it is below 1% but greater than 0%, it is rounded up to 1%.
Scoring example. Suppose you report the Patient-Specific Education measure, which can contribute up to 10% to your performance score. During the performance period, perhaps you see 600 unique patients—this is the denominator. You provided patient-specific educational resources to 200 of those patients (or to their authorized representatives) electronically using clinically relevant information identified from your EHR—this is your numerator. To calculate your performance rate, divide the numerator by the denominator and turn the resulting number into a percentage. In this case, your performance rate would be 33.3% (200/600), and—as indicated in Table 10—this measure will contribute 4% to your ACI score.
Not all performance score measures have a performance rate. The Immunization Registry Reporting measure does not have a performance rate. The 2 measure sets define this measure differently, but in both cases you attest that you have met the measure’s requirements (for the 2 different versions of this measure, see the listings in Table 11 [PDF] and Table 12 [PDF]). If you attest “yes,” your score for the measure is 10%, if you attest “no,” your score is “0%.”
Table 10: Decile-Based Scoring for ACI Performance Measures
|Performance Rate (Numerator/Denominator)
* This scoring applies to ACI performance measures and 2017 ACI transition performance measures that score from 0%-10%.
† If your performance rate is greater than 0% but less than 1%, it will be rounded up to 1%.
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