• MIPS Manual 2017—Quality: MIPS Versus Non-MIPS (QCDR) Measures

    Written By: Rebecca Hancock, Flora Lum, MD, Chris McDonagh, Cherie McNett, Jessica Peterson, MD, MPH, and Sue Vicchrilli, COT, OCS

    This content was excerpted from EyeNet’s MIPS Manual 2017.


    What are MIPS quality measures? MIPS quality measures are those quality measures that are published in the MIPS regulations—there are more than 200 of them, but most of them won’t be applicable to ophthalmologists.

    For your convenience, the Academy has compiled a list of the 31 MIPS quality measures that are most relevant to ophthalmology (see Table 15 [PDF]).

    Which reporting mechanisms can be used for MIPS quality measures? Some measures are available via all 4 reporting mechanisms and others to just 1 or 2. If you are using EHR-based reporting—whether via IRIS Registry integration or via your EHR vendor—you will report MIPS quality measures that evolved out of the electronic clinical quality measures (eCQMs) that previously had been used for the PQRS and EHR meaningful use programs.

    What are non-MIPS quality measures? Non-MIPS quality measures are created for use with Qualified Clinical Data Registries (QCDRs), such as the IRIS Registry, and are sometimes called QCDR measures. Somewhat confusingly, CMS refers to them as non-MIPS quality measures, even though they can be used for MIPS. CMS does this to distinguish them from the MIPS quality measures that were published as part of the regulations.

    Which reporting mechanisms can be used for non-MIPS quality measures? For the 2017 performance year, ophthalmology’s non-MIPS quality measures can be reported manually via the IRIS Registry web portal. If you have integrated your EHR with the IRIS Registry, you will see these non-MIPS quality measures in your dashboard but they can’t currently be reported for MIPS via IRIS Registry/EHR integration. The Academy is reviewing whether it will be feasible in future years to report any of the non-MIPS quality measures via this automated reporting mechanism.

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    Next: Quality: What to Report

    Note: Meeting regulatory requirements is a complicated process involving continually changing rules and the application of judgment to factual situations. The Academy does not guarantee or warrant that regulators and public or private payers will agree with the Academy’s information or recommendations. The Academy shall not be liable to you or any other party to any extent whatsoever for errors in, or omissions from, any such information provided by the Academy, its employees, agents, or representatives.

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