MIPS 2023—Quality Scoring: Some Benchmarks Are Subject to Scoring Limitations

This content is excerpted from EyeNet’s MIPS 2023: A Primer and Reference; 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 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 fifth decile (see Table, below). Thus, with anything less than a perfect performance, scoring stalls at 5.9 achievement points. Furthermore, this benchmark is subject to a 7-point cap, which means that a perfect performance rate would earn you 7 points rather than 10 points. 

Why is a 7-point cap applied to 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.

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. The benchmark for reporting measure 374 manually via a registry is based on performance data from 2021. That year, 50% of participants reported a 100% performance rate (see deciles 6-10) below, which means that a performance rate of 99.99% would only put you in decile 5. Hence, scoring "stalls" at 5.9 points for a performance rate of 99.99%. And because a 7-point cap applies to this benchmark, you score 7 points (rather than 10 points) with a performance rate of 100%.

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