• MIPS Manual 2017—Quality: What to Report

    Written By: Rebecca Hancock, Flora Lum, MD, Chris McDonagh, Cherie McNett, Jessica Peterson, MD, MPH, and Sue Vicchrilli, COT, OCS

    This content was excerpted from EyeNet’s MIPS Manual 2017.


    Reporting Quality Measures

    If you are reporting by claims, the IRIS Registry (EHR integration or the web portal) or your EHR vendor, here’s how you can maximize payment.

    Report on at least 6 quality measures. Your score for the quality performance category will be based on your performance rates for up to 6 quality measures.

    Select your quality measures. The measures available to you will depend on your choice of reporting mechanism. Download Table 15 (PDF) and Table 16 (PDF) for at-a-glance guides that show your reporting options for the quality measures that are most relevant to ophthalmology.

    At least 1 quality measure should be an outcome measure. A measure that is listed as an intermediate outcome measure would be sufficient.

    If no outcome measure is available, you must report another high-priority measure instead. Alternative high-priority quality measures include appropriate use, patient safety, efficiency, patient experience, and care coordination quality measures.

    What if you can’t report on 6 quality measures? If you can’t report on 6 measures, report on as many as you can. CMS instructs you to report on as many as are applicable, and defines applicable to mean “measures relevant to a particular MIPS eligible clinician’s services or care rendered.” The Academy urges you to find at least 6 quality measures to report.

    What if you report on more than 6 quality measures? If you report on 7 or more measures, CMS will determine which 6 of those will give you the highest quality score.

    Consider reporting more than 6 quality measures. You can hedge your bets by reporting on more than 6 measures. Suppose, for example, you are reporting a measure that doesn’t yet have a benchmark. Once the performance year is over, CMS will attempt to calculate a benchmark for that measure. If it doesn’t have enough data to create that benchmark, you will only score 3 points for that measure.

    Meet Quality’s Submission Thresholds

    If your reporting for a quality measure meets both the case minimum requirement and the data completeness criteria, then you may be eligible to earn more than 3 points for that measure (see “Scoring—Your Performance Rate Will Be Compared Against a Benchmark”).

    The case minimum requirement is 20 patients. This applies to all quality measures except for the All-Cause Hospital Readmission measure, which has a case minimum of 200 patients.

    The data completeness criteria—report on at least 50% of applicable patients. For each measure that you report, submit data on at least 50% of applicable patients who were seen during a performance period of at least 90 consecutive days.

    Who are the applicable patients? That depends on your choice of reporting mechanism:

    • If you are submitting data via claims, applicable patients are Medicare patients for whom the measure applies.
    • If you are submitting data via the IRIS Registry web portal, IRIS Registry/EHR integration, or your EHR vendor, applicable patients are Medicare patients and non-Medicare patients for whom the measure applies.

    The data completeness criteria include a Medicare requirement. Report at least 1 Medicare patient for at least 1 quality measure.

    What if you don’t meet the submission thresholds? During the 2017 transition year, if your reporting for a measure fails to meet the data completeness criteria (50% of applicable patients over at least 90 days) or the case minimum requirement (20 patients), you will receive 3 points for that measure.

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    Next: Quality: The All-Cause Hospital Readmission (ACR) Measure for Larger Practices

    Note: Meeting regulatory requirements is a complicated process involving continually changing rules and the application of judgment to factual situations. The Academy does not guarantee or warrant that regulators and public or private payers will agree with the Academy’s information or recommendations. The Academy shall not be liable to you or any other party to any extent whatsoever for errors in, or omissions from, any such information provided by the Academy, its employees, agents, or representatives.

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