This content is excerpted from EyeNet’s MIPS 2021; also see the Academy’s MIPS hub page.
When you report a quality measure, CMS first determines whether you met the two data submission thresholds:
- case minimum requirement (at least 20 patients) and
- the data completeness criteria (at least 70% of applicable patients).
If you meet both of those, CMS will see how your performance rate stacks up against the measure’s benchmark as shown below.
Benchmarks are typically based on historical performance data. CMS used 2019 performance data to try to establish 2021 benchmarks for quality measures.
A quality measure can have up to three different benchmarks. Quality measures typically have separate benchmarks for claims-based reporting, for reporting via manual data entry into the IRIS Registry, and for EHR-based reporting (whether via IRIS Registry integration or via your EHR vendor).
However, the IRIS Registry’s QCDR measures (e.g., IRIS44: Visual Field Progression in Glaucoma) have the same benchmark regardless of whether you are reporting via manual entry or via IRIS Registry–EHR integration.
Also, some measures can’t be reported by all collection types and therefore have fewer than three benchmarks. For example, measure 374: Closing the Referral Loop, can’t be reported via claims.
Your achievement score (3-10 points) for a measure will depend on how your performance compares against the measure’s benchmark. Each benchmark is broken into deciles. Assuming no scoring limitations apply, if your performance rate falls within:
- deciles 1 or 2, you score 3 achievement points
- deciles 3 through 9, your score will depend on where you fall within that decile (e.g., if you fall in the third decile, you can earn between 3.0 and 3.9 achievement points)
- decile 10, you score 10 achievement points.
Table: Scoring for Measure 374 When Reported via IRIS Registry–EHR Integration
If you meet the two data submission thresholds, your achievement points score will be based on how your performance rate compares against the benchmark, with a floor of 3 points.
|Decile 1 or 2
|Note: The above benchmark is only for EHR-based reporting; the benchmark for reporting measure 374 manually via the IRIS Registry has some scoring limitations; 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.)
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