This content is excerpted from EyeNet’s MIPS 2023: A Primer and Reference; also see the Academy’s MIPS hub page.
Did you report enough data for a measure? 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 2021 performance data to try to establish 2023 benchmarks for quality measures.
A quality measure can have up to three different benchmarks. Quality measures can have different measure specifications—and different benchmarks—for different collection types (see “Four Varieties of Measure”). For some measures, different benchmarks apply depending on whether you are reporting it 1) as a claims-based measure, 2) as a MIPS CQM (which typically involves reporting it manually via the IRIS Registry), or 3) as an eCQM (whether via IRIS Registry–EHR integration or via your EHR vendor).
However, 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. And the IRIS Registry’s QCDR measures (e.g., IRIS2: Glaucoma: IOP Reduction) have the same benchmark regardless of whether you are reporting via manual entry or via IRIS Registry–EHR integration.
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 if in a small practice; if in a large practice, your score will depend on where you fall within the decile (e.g., if your score falls in the first decile, you can score between 1.0 and 1.9 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 for small practices.
| Decile |
Performance Rate |
Achievement Points |
| Decile 1 |
0.50%-4.84% |
1.0-1.9 points (large practice)
3.0 points (small practice) |
| Decile 2 |
4.85%-11.35% |
2.0-2.9 points (large practice)
3.0 points (small practices) |
| Decile 3 |
11.36%-17.30% |
3.0-3.9 points (large or small) |
| Decile 4 |
17.31%-23.47% |
4.0-4.9 points (large or small) |
| Decile 5 |
23.48%-30.49% |
5.0-5.9 points (large or small) |
| Decile 6 |
30.50%-38.82% |
6.0-6.9 points (large or small) |
| Decile 7 |
38.83%-50.50% |
7.0-7.9 points (large or small) |
| Decile 8 |
50.51%-66.56% |
8.0-8.9 points (large or small) |
| Decile 9 |
66.57%-85.70% |
9.0-9.9 points (large or small) |
| Decile 10 |
≥ 85.71% |
10 points (large or small) |
| 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 (it "stalls" at decile 5 and is subject to a 7-point cap); the measure can’t be reported via claims. |
Previous: Quality: Manual Reporters Via the IRIS Registry Will Need Their Data-Completeness Totals
Next: Quality Scoring: Some Benchmarks Are Subject to Scoring Limitations
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