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  • MIPS 2020—Quality Scoring: Your Performance Rate Will Be Compared Against a Benchmark

    This content is excerpted from EyeNet’s MIPS 2020; also see the Academy’s MIPS hub page.

    When you report a quality measure, CMS first determines whether you met the two data submission thresholds—the case minimum requirement (at least 20 patients) and the data completeness criteria (at least 70% of applicable patients). If you did, CMS will see how your performance rate stacks up against the measure’s benchmark as shown below.

    Benchmarks are typically based on historical performance data. CMS used 2018 performance data to try to establish 2020 benchmarks for quality measures.

    A quality measure can have up to three different bench­marks. Quality measures typically have separate benchmarks for claims-based reporting, for reporting via manual data entry into the IRIS Registry, and for EHR-based reporting (whether via IRIS Registry integration or via your EHR vendor). However, the IRIS Registry’s QCDR measures (e.g., IRIS2: Intraocular Pressure Reduction) have the same bench­mark regardless of whether you are reporting via manual entry or via IRIS Registry–EHR integration.

    Also, some measures can’t be reported by all collection types and therefore have fewer than three benchmarks. For example, measure 374: Closing the Referral Loop, can’t be reported via claims.

    Your achievement score (3-10 points) for a measure will depend on how you perform against the measure’s bench­mark. Each benchmark is broken into deciles. Assuming no scoring limitations apply, if your perfor­mance rate falls within:

    • deciles 1 or 2, you score 3 achievement points
    • deciles 3 through 9, your score will depend on where you fall within that decile (e.g., if you fall in the third decile, you can earn between 3.0 and 3.9 achievement points)
    • decile 10, you score 10 achievement points.

    Table: Measure 374 When Reported via IRIS Registry–EHR Integration

    The chart below illustrates how your score for a measure—in this case Measure 374: Closing the Referral Loop—will be based on how your performance rate compares to a benchmark. (Note: The benchmark for manually reporting this measure has some scoring limitations; this measure is not available for claims-based reporting.) 

    Decile Integrated IRIS Registry–EHR Reporting
    Performance Rate (%) Points
    d3 0.23–2.62 3.0–3.9
    d4 2.63–10.46 4.0–4.9
    d5 10.47–37.69 5.0–5.9
    d6 37.7–68.19 6.0–6.9
    d7 68.2–90.18 7.0–7.9
    d8 90.19–97.42 8.0–8.9
    d9 97.43–99.99 9.0–9.9
    d10 100 10
    Scoring Summary 3-10 points

    Previous: Quality: Meet the Data Submission Thresholds

    Next: Quality Scoring: Some Benchmarks Are Subject to Scoring Limitations

    DISCLAIMER AND LIMITATION OF LIABILITY: 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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    All of the American Academy of Ophthalmology (AAO)–developed quality measures are copyrighted by the AAO’s H. Dunbar Hoskins Jr., MD, Center for Quality Eye Care (see terms of use).