This content is excerpted from EyeNet’s MIPS 2023: A Primer and Reference; also see the Academy’s MIPS hub page.
Since 2018, CMS has required practices that report quality measures manually through registries to submit data-completeness totals for each quality measure reported. (Note: This is different from the 70%–data completeness criteria.)
What data-completeness total(s) must you submit for each quality measure? For each quality measure that you report manually via the IRIS Registry, do the following:
- Report the total number of patients seen during the year (from all payers) who were eligible for the measure
- If the measure includes an exception, report the total number of patients excepted from the measure
If you are reporting manually via the IRIS Registry, you won’t be able to submit a measure’s quality data to CMS without including the total number of eligible patients and, if applicable, the total number of excepted patients. Even if you want to report the measure for just one patient, CMS will want to know how many patients the measure could have been reported on over the calendar year.
Contact the vendor of your billing system. Many practices will be able to readily collect the eligible patient totals from their billing systems. Contact your billing system vendor and ask for instructions on how to run the appropriate reports.
Find out which patients would be eligible for each of your quality measures. At the IRIS Registry dashboard, you can view detailed measure specifications of each quality measure that you plan to report. The detailed measure descriptions include the denominator criteria that indicate which patients qualify for each measure.
Report the Eligible Totals
Get the total number of eligible patients for quality measures. After determining the denominator criteria, use your billing system to run a report of patients who meet those criteria. This will give you the total number of patients eligible for the measure. (Note: Run these reports after the end of the calendar year.)
Example: Determining the total number of eligible patients for Measure 12: Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation. Run a report in your billing system for the date range “1/1/23-12/31/23.” Apply a filter for the following:
- Diagnosis of POAG (using ICD-10 codes outlined in the measure specification)
- Eligible CPT codes billed during the 2023 calendar year (using CPT codes outlined in the measure specifications)
- Date of birth, so that only patients age 18 years and older are included. If your system doesn’t have this functionality, you can print out the report using the diagnosis- and CPT code–criteria and then remove patients who do not meet the measure’s age criteria.
Report the Exceptions
Get the total number of patient exceptions for a quality measure. Some quality measures have exceptions. These are often medical- or patient-related. For example, there may be a medical reason why you can’t perform an optic nerve evaluation on a patient with POAG. Such exceptions should be supported by documentation. It may be difficult to run a report in your billing system to produce this total, and it may require manual counting.
Some quality measures do not have exceptions. Not all quality measures include exceptions. For example, there are no exceptions for the manually reported measures developed by the IRIS Registry (IRIS1, IRIS2, etc.).
Can’t Get These Totals Electronically?
Some practices collect data manually by adding a MIPS worksheet to the charts. If you are not able to use your billing system to collect the number of patients eligible for a quality measure and/or the number excepted from the measure, you can use a manual approach for gathering this information. For example, some practices set up a manual system at the start of the year: They create a quality measure worksheet that they place in every patient’s chart. This worksheet asks for all the information that is needed for the measures that the practice plans to report, and staff are trained to fill it out at each patient visit. This data can be used to calculate the eligible patients and exceptions.
Some practices keep up with their MIPS data entry throughout the year. Some practices manually enter 100% of eligible patients into the IRIS Registry throughout the year on a daily, weekly, or monthly basis. Both the eligible totals and the patient exception totals will be captured during that reporting, and the practice will have them on hand in early 2023 when it is time to submit its quality data to CMS.
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