This content is excerpted from EyeNet’s MIPS 2021; also see the Academy’s MIPS hub page.
If your reporting for a measure meets the two data submission thresholds, your performance rate will be compared against a benchmark and you can earn achievement points depending on how your performance stacks up. For some benchmarks, the full range of 3-10 achievement points is available. However, some benchmarks are subject to scoring limitations. When you review the table(s) of quality measures for your chosen collection type(s), watch for benchmarks where scoring “stalls” or that are subject to a 7-point cap, and be mindful of measures that don’t yet have a benchmark.
Scoring “stalls” for some benchmarks due to high performance rates. The scoring for some benchmarks approaches maximum performance before the ninth decile. If, for example, you use the IRIS Registry to manually report measure 374: Closing the Referral Loop, the relevant benchmark reaches a 99.99% performance rate at the seventh decile (see Table, below). You can still earn 10 achievement points with a 100% performance rate, but with a less-than-perfect performance, scoring stalls at 6.9 achievement points.
A 7-point cap for some benchmarks. Once a quality benchmark is in its second year of being “topped out” it becomes subject to a 7-point cap.
What is a topped out benchmark? CMS considers a benchmark to be topped out if there is limited opportunity for improvement. For example, a process-based measure is considered topped out if the median performance rate was at least 95%. CMS is concerned that such benchmarks provide very little room for improvement for most of the MIPS eligible clinicians who use those measures.
The end of the line for some topped out benchmarks. Once a benchmark is topped out for three consecutive performance years, CMS will consider eliminating it in the fourth year. Furthermore, if CMS finds that a benchmark is extremely topped out (e.g., average performance rate of a process-based measure is 98% or higher), it may eliminate it the following year.
What if there is no benchmark? If there wasn’t enough performance data from 2019 to establish a reliable benchmark for a measure, or if the measure didn’t exist in 2019, CMS will try to establish a benchmark retroactively using 2021 performance data. However, CMS won’t assign a benchmark to a measure unless at least 20 clinicians or groups submit performance data that meet the two data submission thresholds.
Table: Scoring for Measure 374 When Reported Manually via the IRIS Registry
If you meet the two data submission thresholds, your achievement points score will be based on how your performance rate compares against a benchmark, with a floor of 3 points. The benchmark for reporting measure 374 manually via a registry is based on performance data from 2019. That year, 40% of participants reported a 100% performance rate (see deciles 7-10) below, which means that a performance rate of 99.99% would only put you in decile 6. Hence, scoring "stalls" at 6.9 points for a performance rate of 99.99%; you can score 10 points with a performance rate of 100%.
| Decile |
Performance Rate |
Achievement Points |
| Decile 1 or 2 |
<60.00% |
3 points |
| Decile 3 |
60.00%-77.54% |
3.0-3.9 points |
| Decile 4 |
77.55%-92.30% |
4.0-4.9 points |
| Decile 5 |
92.31%-97.54% |
5.0-5.9 points |
| Decile 6 |
97.55%-99.99% |
6.0-6.9 points |
| Decile 7-10 |
100% |
10 points |
| Note: The above benchmark is only for manually reporting measure 374 via the IRIS Registry; there is a different benchmark for reporting measure 374 via IRIS Registry–EHR integration and the measure can’t be reported via claims. (UPDATE: On June 10, 2021, CMS announced that it was making corrections to almost all quality benchmarks; the above Table has been updated with the revised benchmark data.) |
If CMS is unable to establish a benchmark for a measure, you won’t be able to earn more than 3 achievement points for reporting that measure.
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