MIPS 2019—Reporting MIPS Quality Measures Manually via the IRIS Registry

This content was excerpted from EyeNet’s MIPS 2019; also see the Academy’s MIPS hub page. 

If  you are using the IRIS Registry to manually report quality measures, you can choose from 29 MIPS clinical quality measures (MIPS CQMs) and 28 QCDR measures (the IRIS measures).

In the chart below, those measures are grouped by area of focus. There are preventative health measures, cataract/anterior segment measures, cornea/external disease measures, glaucoma measures, neuro-ophthalmology measures, oculofacial plastics/reconstructive measures, pediatric ophthalmology and strabismus measures, refractive surgery measures, retina/vitreous measures, and uveitis/immunology measures. In addition to considering the measures in your subspecialty, you should review the measures in the other subspecialties in case any might be relevant to you. (And don’t forget to review "Tips on Using This Chart.")

Harder to get a high score for quality. In 2019, if you report the same quality measures as you did in 2018 and get similar performance rates, you are likely to score fewer achievement points. Why? The benchmarks for most quality measures have become more demanding, more measures are in their second year of being topped out, which means they are subject to a 7-point cap (see Table 6A), and scoring for more measures “stalls” below the 10th decile (see Tables 6B and 6C). 

Table 8: Manually Reporting Quality Measures via the IRIS Registry

Tips on Using This Chart

This chart shows the benchmarks for quality measures reported manually via the IRIS Registry. You also can report via IRIS Registry–EHR integration and via Medicare Part B claims.

Column 1—ID: Measure Name

Learn more about a measure by clicking on its name. Each measure’s name is linked to a detailed web page that explains which patients are denominator eligible, lists relevant ICD-10 and CPT codes, describes how to report the measure, and provides detailed benchmark information.

Which measures should you report? Skim through this chart to see which measures you are most likely to (a) satisfy the case minimum requirement of 20 patients, (b) satisfy the 60%-data completeness criteria, and (c) achieve a high performance rate.

Other factors to keep in mind are that you need to report at least one quality or intermediate quality measure (or if neither of those are available to you, some other type of high-priority measure); you can earn high-priority bonus points for some measures; and you should watch for measures where scoring stalls before the 10th decile (especially if they stall at a low decile), measures that are subject to a 7-point cap, and measures that don’t yet have a benchmark. 

Column 2—High-Priority Measures (Bonus Points)

Report at least one outcome measure. You need to report at least six quality measures, and at least one of them should be an outcome measure or an intermediate outcome measure (or if none is available, you must report another type of high-priority measure).

Earn high-priority bonus points. After reporting the initial, mandatory outcome or other high-priority measure (see above), you earn bonus points for submitting additional high-priority measures.

Column 3—Achievement Points

For many quality measures, you can earn 3-10 achievement points. Your score will depend on how your performance rate compares against a measure’s benchmark, which is split into deciles. If your performance rate falls within the benchmark’s 10th decile, you earn 10 achievement points; if it falls within the benchmark’s ninth decile, you earn 9.0-9.9 achievement points; if it falls within the benchmark’s eighth decile, you earn 8.0-8.9 achievement points; etc. (Example: Benchmark for measure 374: Closing the Referral Loop.)

Why does the point range for each measure start at 3 points? Provided you satisfy the 60%-data completeness criteria for a measure, there is a floor of 3 achievement points for reporting that measure. Thus, if your performance rate fell below the performance rate associated with the third decile, you would earn 3 achievement points. (If you didn’t satisfy the 60%-data completeness criteria, you would earn 3 achievement points if you are in a small practice, 1 point if you are in a large practice.)

Why does the point range for some measures peak at 7 points? Some quality measures are subject to a 7-point cap (see below).

Scoring for some quality measures temporarily “stalls” below the 10th decile. The benchmarks for some quality measures approach perfect performance before the 10th decile. For instance, the benchmark for measure 402: Tobacco Use and Help With Quitting Among Adolescents reaches a performance rate of 99.99% at the eighth decile. Consequently, if your performance rate is 99.99%, you would only earn 8.9 achievement points; however, a performance rate of 100% would earn you 10 achievement points (the chart indicates this in the “Achievement Points” column, by noting “3-6.9 points or, with a 100% performance rate, 10 points”). Some measures with stalled scoring also are subject to the 7-point cap.   

What if a quality measure doesn’t yet have a benchmark? CMS used 2017 performance data to try and establish 2019 benchmarks for quality measures. If there isn’t enough 2017 performance data to establish a reliable benchmark for a measure, or if the measure didn’t exist in 2017, CMS will try to establish a benchmark retroactively using 2019 performance data. If it is still unable to establish a benchmark for a measure, you won’t be able to earn more than 3 achievement points for reporting that measure.

Different benchmarks for different collection types. This chart refers to the benchmarks that would be used if you are reporting manually via the IRIS Registry. There can be other benchmarks for EHR-based reporting (which would apply if you are reporting via IRIS Registry–EHR integration or via your EHR vendor) and for for claims-based reporting.

Column 4—Notes

What are inverse measures? An inverse quality measure is one where you earn more achievement points for a lower performance rate. (Example: Measure 1: Diabetes: Hemoglobin A1c Poor Control [>9%].)

What’s the 7-point cap? Once a quality measure is in its second year of being topped out, you won’t be able to score more than 7 achievement points for it (for example, see Table 6A and Table 6C).

What are topped out measures? CMS considers a measure to be topped out when a lot of clinicians are attaining, or almost attaining, maximum performance for that measure (e.g., the average performance rate is 95% or higher). CMS had previously established a four-year life cycle for such measures—if they are topped out for at least two years, they would be subject to a 7-point cap; topped out for three consecutive performance years, they would be eliminated in the fourth year. 

What are extremely topped out measures? If CMS considers a measure to be extremely topped out (e.g., the average performance rate is 98% or higher), it can be removed from MIPS the following year, even if it hasn’t been topped out for three consecutive years. (Note: Topped out QCDR measures also are on an accelerated timetable for removal from MIPS, even if they aren’t extremely topped out.)

Previous: Table 7: Reporting Quality Measures via IRIS Registry–EHR Integration

Next: Table 9: Reporting Quality Measures via IRIS Medicare Part B Claims

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