• MIPS 2021—Quality: Reporting Quality Measures

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


    Here’s how you can maximize your quality score.

    Report at least one outcome measure. A measure that is listed as an intermediate outcome measure or a patient-reported outcome measure would suffice.

    If no outcome measure is available, you must report another high-priority measure instead. Alternative high-priority quality measures include appropriate use, care coordination, efficiency, patient experience, patient safety, and opioid-related measures.

    Report at least six quality measures (including the one mentioned above). Your quality score will be based on your achievement points for up to six quality measures, plus high-priority and CEHRT bonus points, and your quality improvement percent score.  

    What if you report on more than six quality measures? If you report on seven or more measures, CMS will determine which six of those measures will give you the highest number of measure achievement points based on your performance rates, with the caveat that one of them must be an outcome measure. Furthermore, if you report high-priority quality measures, the high-priority bonus point(s) for those mea­sures can contribute to your score regardless of whether they are among the six measures that contribute to your measure achievement score.

    Select your quality measures. The quality measures that are available to you will depend on which collection type you use. Review these at-a-glance charts to see what measures are available for each collection type, and to see which of those measures are subject to scoring limitations

    Tip: Look for measures where you are most likely to 1) satisfy the case minimum of 20 patients, 2) satisfy the 70%–data com­pleteness criteria, and 3) achieve a high performance rate. Also be mindful of measures that have scoring limitations—such as score-stalling or a 7-point cap—or that don’t yet have a benchmark.

    If you report manually via the IRIS Registry, you need additional data on patient counts. When you report a qual­ity measure manually via a Qualified Clinical Data Registry (QCDR), such as the IRIS Registry, you must include 1) the number of patients eligible for that measure and 2) for mea­sures that include exceptions, the number of patients for whom the exception applies.

    Report more than six quality measures to give yourself a margin of error. In case you run into a problem with one of your quality measures, you can hedge your bets by report­ing more than six of them. Suppose, for example, you are reporting a measure that doesn’t yet have a benchmark. Once the performance year is over, CMS will attempt to calculate a benchmark for that measure. But if it doesn’t have enough data to create a reliable benchmark, you won’t be able to score more than 3 achievement points for that measure.

    Understand the measure specifications: Familiarize yourself with the mea­sures that you expect to be scored on and make sure that you are performing and documenting them in line with their current specifications. If you report via the IRIS Registry, you can access detailed measure specifications via your dashboard. You also download these PDFs from the 2021 Clinical Quality Measure Specification and Benchmark Table at  aao.org/medicare/quality-reporting-measures.

    Ask the practice’s clinicians to review their performance. If you are reporting via the IRIS Registry, give each care provider their IRIS Registry report so they can see their performance across the quality measures.

    What is the HWR measure? As an ophthalmologist, it is very unlikely that you will be scored on quality measure 479: Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS. You would need to have a high volume of unplanned readmissions to a hospital within 30 days of an initial discharge. This measure only applies to large groups (16 or more eligible clinicians) that meet the case minimum requirement of 200 cases involving patients aged 65 or older. Such practices don’t need to report this measure; they will be evaluated based on Medicare ad­ministrative claims data. This new measure replaces quality measure 458: All-Cause Hospital Readmission (ACR).

    Previous: Quality: Pick Your Collection Type(s)

    Next: Quality: Meet the Data Submission Thresholds 

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