MIPS 2020—Reporting MIPS Quality Measures Manually via the IRIS Registry

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

Table: Reporting Manually Via the IRIS Registry (No EHR Needed)

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. To help you make the most of these pages, the Academy has developed a guide to reading quality measures (PDF).

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 70%-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 outcome or intermediate outcome measure (or if neither of those are available to you, some other type of high-priority measure);
• you can earn bonus points for reporting additional high-priority measures (see column 2);
• you should watch for measures where scoring stalls before the 10th decile—especially if they stall at a low decile (see column 3);
• you should watch for measures that are subject to a 7-point cap (see column 4); and
• you should be mindful of measures that don’t yet have a benchmark (see column 3).

Column 2—High-Priority Measures (Bonus Points)

Report at least one outcome measure. 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 some 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, depending on where it falls within that benchmark; if it falls within the benchmark’s eighth decile, you earn 8.0-8.9 achievement points; etc.

Why does scoring for a measure start at 3 points? Provided you satisfy the 70%-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 70%-data completeness criteria, you would earn 3 achievement points if you are in a small practice, 0 points if you are in a large practice.)

Why does scoring 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” before the 10th decile. The benchmarks for some quality measures approach perfect performance before the 10th decile. For example, measure 110, which is the influenza immunization measure, has a benchmark that 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 “3-8.9 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 2018 performance data to try and establish 2020 benchmarks for quality measures. If there isn’t enough 2018 performance data to establish a reliable benchmark for a measure, or if the measure didn’t exist in 2018, CMS will try to establish a benchmark retroactively using 2020 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 are other benchmark charts to review if you are reporting via IRIS Registry–EHR integration or via Medicare Part B claims.

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 is 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.

What is a flat benchmark? A flat benchmark is not based on performance data. Instead, it is based on a simple formula: A performance rate of 90% or more earns you 10 achievement points; a performance rate of 80%-88.9% earns you 9 achievement points, etc. For inverse measures that have a flat benchmark, such as measure 1, a performance rate of 10% or less earns you 10 achievement points, a performance rate of 10.1-20% earns you 9 achievement points, etc. 

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).

Topped out measures have a limited life cycle. If a measure is topped out for at least two years, it is subject to a 7-point cap; topped out for three consecutive performance years, CMS will consider eliminating it 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.)

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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).