• MIPS 2019—Quality: Meet the Data Submission Thresholds

    This content was excerpted from EyeNet’s MIPS 2019; also see the Academy’s MIPS hub page


    When you report a measure, aim to meet both the case minimum requirement and the data completeness criteria.

    The case minimum requirement is 20 patients. The exception is the ACR measure, which has a 200-patient case minimum.

    The data completeness criteria—report on at least 60% of denominator-eligible patients. For each measure that you report, submit data on at least 60% of denominator-eligible patients who were seen during the entire 2019 calendar year.

    Who are the denominator-eligible patients? That depends on the quality measure, and it also depends on how you are reporting. Suppose, for example, you are reporting measure 117: Diabetes: Eye Exam. The denominator-eligible patients for that measure would be those with diabetes who are 18-75 years old. If you are reporting by claims, you would just include Medicare patients; if you are using any other reporting mechanism, you would include both Medicare and non-Medicare patients. Your reporting will indicate what percentage of those patients had an eye screening for diabetic retinal disease. (To see the denominator criteria for quality measures, see the Academy’s detailed listings for the quality measures.)

    If you report on fewer than 100% of patients, do not cherry-pick. When you submit your MIPS quality data to CMS, you must certify that, to the best of your knowledge, your data is “true, accurate, and complete.” In the Aug. 14, 2019 edition of the Federal Register, CMS clarified that if you report on a measure for fewer than 100% of applicable patients, you should not select patients with the goal of boosting your performance rate; the agency states that such “cherry-picking” would result in data that is not “true, accurate, and complete.” 

    What if you don’t meet the case minimum requirement for a reported measure? You will score 3 achievement points for it, provided you satisfy the data completeness criteria.

    What if you don’t satisfy the data completeness criteria for a reported measure? Provided that you report at least one patient, you will score 1 achievement point if you are in a large practice or 3 achievement points if you are in a small practice. (See Small or Large Practice? to learn how CMS determines practice size.)

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