• MIPS 2020—Quality: Who Reports Data Completeness Totals?

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


    What is the data-completeness requirement? Since 2018, CMS has required practices that report quality measures manually through registries to submit data-completeness totals for each quality measure reported. Even if an eligible clinician or practice reports a measure for just one patient, CMS wants to know how many patients the measure could have been reported on over the calendar year. 

    Are you reporting a quality measure via the IRIS Registry? If so, you must do the following:

    • Report the total number of patients eligible for the measure
    • If the measure includes an exception, report the total number of patients excepted from the measure

    You won’t be able to submit a measure’s quality data to CMS without including the eligible patients total and, if applicable, the excepted patients total.

    Contact the vendor of your billing system. Many practices will be able to readily collect the eligible patient totals from their billing systems. Contact your billing system vendor and ask for instructions on how to run the appropriate reports.

    Get the total number of eligible patients for quality measures. First view the detailed specifications for each quality measure you report. They are posted at aao.org/medicare/quality-reporting-measures.

    The detailed measure descriptions include the denominator criteria that indicate which patients qualify for each measure. After determining the denominator criteria, use your billing system to run a report of patients who meet those criteria. This will give you the total number of patients eligible for the measure. (Note: Run these reports after the end of the calendar year.)

    Example: Determining the total number of eligible patients for Measure 12: Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation. Run a report in your billing system for the date range “1/1/20-12/31/20.” Apply a filter for the following:

    • Diagnosis of primary open-angle glaucoma (using ICD-10 codes outlined in the measure specification)
    • Eligible CPT codes billed during the 2020 calendar year (using CPT codes outlined in the measure specification)
    • Date of birth, so that only patients age 18 and older are included. If your system doesn’t have this functionality, you can print out the report using the diagnosis- and CPT code–criteria and then remove patients who do not meet the measure’s age criteria.

    Get the total number of patient exceptions for a quality measure. Some quality measures have exceptions. These are often medical- or patient-related. For example, there may be a medical reason why you can’t perform an optic nerve evaluation on a POAG patient. Such exceptions should be supported by documentation. It may be difficult to run a report in your billing system to produce this total, and it may require manual counting. Note: If you have manually entered 100% of eligible patients into the IRIS Registry, the patient exceptions would already be captured, and you would already have the total number of patients excepted from the measure.

    Gathering data manually. If you are not able to use your billing system to collect the number of patients eligible for a quality measure and/or the number excepted from the measure, you will need a manual approach for gathering this information. 

    Some quality measures do not have exceptions. Of the quality measures that can be manually reported via the IRIS Registry, the following do not have exceptions: Measures 1, 111, 117, 141, 191, 236, 238, 374, 384, 385, 389, 402, and the manually reported measures developed by the IRIS Registry (IRIS1, IRIS2, etc.).

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