• MIPS 2018—Overview 1: The Quality Performance Category

    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 2018; also see the Academy’s MIPS hub page


    Pick your reporting mechanism for quality measures: If you don’t have a certified EHR system, you can choose to report via:

    • claims or
    • the IRIS Registry web portal.

    If you do have a certified EHR system, you also can report via:

    • IRIS Registry/EHR integration or
    • your EHR vendor.

    Which quality measures should you report? If you report via IRIS Registry/ EHR integration, you can let an automated process select which quality measures would give you the highest score. If you are using another reporting mechanism, choose which measures would work best for you: Browse the Academy’s online listings of measures or view 2 at-a-glance tables (PDF) of the standard MIPS quality measures (Table 11) and the ophthalmology-specific QCDR quality measures (Table 12). Your ability to get a high score for a measure may be limited if it is topped out or it doesn’t yet have a benchmark.

    Reporting at a Glance

    For all 4 of the reporting mechanisms listed above, your reporting requirements are as follows.

    To maximize your quality score, you should do the following:

    • Report at least 6 quality measures. Up to 6 quality measures contribute achievement points to your quality score; if you report more than 6, the extra measures can contribute bonus points, but not achievement points, to your quality score.
    • Include at least 1 outcome quality measure (if no outcome measure is available, report another high-priority measure). 

    Editor’s note: Other reporting options—such as CMS Web Interface and MIPS APMs—involve different reporting requirements.

    Meet 2 data submission thresholds: For each quality measure that you report, you should do both of the following:

    1. Meet the case minimum requirement: Report at least 20 cases.
    2. Meet the data completion criteria: Submit data for at least 60% of …
    • Medicare patients (if submitting by claims) or
    • Medicare and non-Medicare patients (if submitting data via the IRIS Registry or your EHR vendor)

    … who were seen during the 2018 calendar year and to whom the measure applies.

    What if you report more than 6 quality measures? CMS will select the 6 measures that give you the most achievement points based on your performance rates; the remaining measures can still contribute bonus points (see below).

    Scoring Summary

    You can earn achievement points, high-priority bonus points, and CEHRT bonus points.

    How you earn achievement points:
    If you submit data for a quality measure, CMS determines whether you met both of the submission thresholds:

    How you earn high-priority bonus points: Some quality measures are designated high-priority measures. There are 6 types of high-priority measure: Outcome, patient experience, appropriate use, care coordination, efficiency, and patient safety. You get no bonus points for your first outcome measure (or alternate high-priority measure), but after that you get:

    • 2 bonus points for an outcome or patient experience measure, and
    • 1 bonus point for an appropriate use, care coordination, efficiency, or patient safety measure. 

    CEHRT bonus points: You may get 1 bonus point for each quality measure submitted using EHR or IRIS Registry/EHR integration.

    Up to 12 (or 14) bonus points: The high-priority and CEHRT bonuses are each capped at 6 or—in the unlikely event that you are scored on the All-Cause Hospital Readmission measure—7 points.

    All-Cause Hospital Readmission (ACR) measure: Larger groups (≥ 16 eligible clinicians) with at least 200 ACR cases will be scored on the ACR measure (up to 10 points). You don’t need to report anything; assessment is based on administrative claims. Most ophthalmologists will not be evaluated on this measure.

    New: Score extra points for quality improvement. If you scored more achievement points in 2018 than you did in 2017, then you may get an improvement percent score, which is capped at 10 points.

    Calculating your quality perfor­mance score (0%-100%): CMS determines your numerator. This is your total number of achievement points earned on as many as 6 measures plus, if applicable, your ACR points, plus your total bonus points.

    Next, CMS divides that numerator by your denominator, which is 60 (or 70 if the ACR measure applies).

    Finally, CMS turns the resulting fraction into a percentage (capped at 100%).

    This percentage is added to your improvement percent score to determine your score for the quality performance category.

    Example: A small group practice reports 6 quality measures and scores 37.5 points, based on its performance rate for those measures. It also scores a 3-point bonus for reporting high-priority measures and a 6-point CEHRT bonus. It adds those together (37.5 + 3 + 6) to determine its numerator (46.5). Because this is a small practice, the ACR measure does not apply, so the denominator is 60. To determine its quality score, it divides the numerator by the denominator (46.5/60), turns the resulting fraction into a percentage (77.5%), and then adds the improvement percent score. Suppose, for example, the improvement percent score is 2.5%, the quality score would be 80%.

    Your quality score (0%-100%) con­tributes up to 50 points to your MIPS final score. Example: If a physician’s quality score is 80%, it would contribute 40 points (80% of 50) to her final score.

    Want to know more about quality? Take a deeper dive, starting with Quality: Select a Reporting Mechanism.

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    Previous: Nuts and Bolts: Next Steps.

    Next: Overview 2: The Promoting Interoperability (Formerly ACI) Performance Category.

    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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