• MIPS 2021—Quality: Meet the Data Submission Thresholds

    This content is excerpted from EyeNet’s MIPS 2021; also see the Academy’s MIPS hub page.


    When you report a measure, you must meet both the case minimum requirement and the data completeness criteria in order to earn achievement points based on your perfor­mance rate and, for a high priority measure, earn high-priority bonus points. 

    The case minimum: Report on at least 20 patients. The exception is the Hospital-Wide Readmission (HWR) mea­sure, which has a 200-patient case minimum.

    The data completeness criteria: Report on at least 70% of denominator-eligible patients. For each measure that you report, submit data on at least 70% of denominator-eligible patients who were seen during the entire 2021 calendar year.

    Who are the denominator-eligible patients? That depends on the quality measure as well as on what collec­tion type you are using to report that measure. Suppose, for example, you are reporting measure 117: Diabetes: Eye Exam. The denominator-eligible patients for that measure would be those with diabetes who are 18-75 years old. If you are reporting via the Medicare Part B claims collection type, you would just include Medicare patients; if you are using any other reporting mechanism, you would include both Medicare and non-Medicare patients. Your reporting will in­dicate what percentage of those patients had an eye screening for diabetic retinal disease. (Where can you find the denom­inator criteria for quality measures? If you are reporting via the IRIS Registry, you can find that information in your dashboard. If reporting via claims, you can download the specifications for claims-based measures at https://qpp.cms.gov/mips/explore-measures/quality-measures.)

    What if you don’t meet the case minimum requirement for a reported measure? You will score 3 achievement points for it, provided you satisfy the data completeness criteria. 

    What if you don’t satisfy the data completeness criteria for a reported measure? If in a large practice, you earn no points; if in as small pracitce, you score 3 achievement points provided that you report at least one patient. (To learn how CMS assigns practice size, see ”Small or Large Practice?”)

    Do Not Cherry-Pick Your Patients

    If you report on fewer than 100% of patients, do not cherry-pick. If you report on a measure for fewer than 100% of applicable patients, you must not cherry-pick patients with the goal of boosting your performance rate. The MIPS regulations address this when it states that if “quality data are submitted selectively such that the submitted data are unrepresentative of a MIPS eligible clinician or group’s performance, any such data would not be true, accurate, or complete.” In an audit, you’d be failed for cherry picking.

    Previous: Quality: Reporting Quality Measures

    Next: Quality: Manual Reporters Via the IRIS Registry Will Need Their Data-Completeness Totals 

    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.

    COPYRIGHT© 2021, American Academy of Ophthalmology, Inc.® All rights reserved. No part of this publication may be reproduced without written permission from the publisher. American Academy of Ophthalmic Executives® and IRIS® Registry, among other marks, are trademarks of the American Academy of Ophthalmology®.

    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).