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.)
||Integrated IRIS Registry–EHR Reporting
|Performance Rate (%)
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