• MIPS Manual 2017—Know the Basics: Quality Overview

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

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

    Table 5: Quality Overview

    First Steps

    Decide whether to participate in MIPS as an individual or as part of a group. You must participate in the same way for all performance categories. There are pros and cons to both approaches. (See “The Pros and Cons of Group Reporting.”)

    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.

    Pick which quality measures to report. Your choice of reporting mechanism will determine which measures you can choose from. Download Table 15 (PDF) and Table 16 (PDF) for at-a-glance guides that shows your reporting options for the quality measures that are most relevant to ophthalmology.

    Reporting at a Glance

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

    You can avoid the MIPS payment penalty with minimal reporting. Just report on 1 quality measure, 1 time for 1 patient.

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

    • Report at least 6 quality measures. Up to 6 quality measures contribute to your quality score; if you report more than 6, CMS will use the 6 measures that produce the highest 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.

    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 50% 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 a period of at least 90 consecutive days and for whom the measure applies. This period of at least 90 days is known as the performance period. For some quality measures, you may get a higher score with a longer performance period.*

    Report at least 1 Medicare patient. The data completion criteria include a requirement that you include data for at least 1 Medicare patient for at least 1 quality measure.

    Scoring Summary

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

    • If so, you get 3-10 points, based on how you compare against a benchmark for that measure.†
    • If not, you get 3 points.

    High-priority bonus points: You get no bonus points for your first high-priority measure, but after that you get:

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

    CEHRT bonus points: You may get 1 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—if you are scored on the All-Cause Hospital Readmission measure—7 points.

    All-Cause Hospital Readmission (ACR) measure: Larger groups (> 15 MIPS eligible clinicians) with at least 200 ACR cases will also 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.

    Calculating your quality performance score (0%-100%): 

    1) CMS determines your numerator, which is your total number of points earned on as many as 6 measures plus, if applicable, your ACR points (if you submit data for more than 6 measures, CMS will determine which 6 would give you the highest score);

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

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

    This percentage is your quality performance score.

    Example: A large group practice reports 6 quality measures and scores 41.5 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 (41.5 + 3 + 6) to determine its numerator (50.5). Because the ACR measure applies, the denominator is 70. To determine its quality score, it divides the numerator by the denominator (50.5/70) and turns the resulting fraction into a percentage (72.14%).

    Your quality score (0%-100%) contributes up to 60 points to your MIPS final score. Example: If a physician’s quality score is 72.14%, it would contribute 43 points (72.14% of 60) to her final score.

    For a deeper dive, see “Quality: Select a Reporting Mechanism.”

    * You may need a longer performance period if you are going to satisfy the case minimum criteria. And for some measures—e.g., “Cataracts: 20/40 or Better Visual Acuity Within 90 Days Following Cataract Surgery”—if your performance period is less than a year, you’ll be at a disadvantage when your data is compared against a benchmark that is based on 12 months of data.

    † Editor’s note: Your scoring may be limited if a measure has no benchmark (see “Scoring—Watch for Measures That Don’t Yet Have Benchmarks”) or is topped out (seeScoring—Watch for Measures That Are Topped Out).


    Next: Know the Basics: Timeline for MIPS 2017

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