• MIPS 2019—Quality: Reporting Quality Measures

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


    Here's how you can maximize your quality score.

    Report at least one outcome measure. A measure that is listed as an intermediate outcome measure or a patient-reported outcome measure would suffice.

    If no outcome measure is available, you must report another high-priority measure instead. Alternative high-priority quality measures include appropriate use, patient safety, efficiency, patient experience, care coordination measures, or—new this year—opioid-related measures.

    Report at least six quality measures (including the measure mentioned above). Your score for the quality performance category will be based on your performance rates for up to six quality measures, plus high-priority and CEHRT bonus points, and your quality improvement percent score.

    Select your quality measures. Table 7 shows the quality measures that you can report via IRIS Registry–EHR integration, with the caveat that you can only report a quality measure via integrated reporting if the IRIS Registry is able to extract the relevant data from your EHR system. 

    Table 8 shows the measures that you can report via IRIS Registry manual reporting.

    Table 9 shows the claims-based measures that are most relevant to ophthalmology, but there are many more (explore them all on the CMS website, but make sure you select “Medicare Part B claims measures” as the collection type).

    Tables 7, 8 and 9 all do the following:

    • link to detailed web pages for each measure (click the link in column 1)
    • flag high-priority measures (column 2)
    • indicate how many achievement points can be scored for a measure (column 3)
    • indicate whether a measure is an inverse measure, topped out, or subject to a 7-point cap (column 4)

    Note: Scoring limitations limit how many achievement points are available for some measures.

    What if you report on more than six quality measures? If you report on seven or more measures, CMS will determine which six of those measures will give you the highest number of measure achievement points based on your performance rates, with the caveat that one of them must be an outcome measure. Furthermore, if you report high-priority quality measures, the high-priority bonus point(s) for those measures can contribute to your score regardless of whether they are among the six measures that contribute to your measure achievement score. The high-priority bonus is subject to a 6- or 7-point cap (depending on whether or not you are scored on the ACR measure), and you don’t score bonus points for the initial, obligatory outcome measure. 

    If you report manually via the IRIS Registry, you need additional data on patient counts. When you report a quality measure manually via a QCDR (such as the IRIS Registry), you must include:

    1) the number of patients eligible for that measure and
    2) for measures that include exceptions, the number of patients for whom the exception applies.

    If you have an administrative billing system, ask your vendor to help you run reports to get this data. For more on this requirement, see the IRIS Registry’s guide to data completeness. Also visit the Academy’s detailed web pages on the quality measures, which include denominator descriptions that explain patient eligibility. (Tip: Download the Academy’s guide to reading the quality measures [PDF].)

    Report more than six quality measures to give yourself a margin of error. You can hedge your bets by reporting more than six quality measures. Suppose, for example, you are reporting a measure that doesn’t yet have a benchmark. Once the performance year is over, CMS will attempt to calculate a benchmark for that measure. If it doesn’t have enough data to create that benchmark, you won’t be able to score more than 3 achievement points for that measure.)

    Previous: Quality: Decide How You Will Report

    Next: Quality: Meet the Data Submission Thresholds

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    All of the American Academy of Ophthalmology (AAO)–developed quality measures are copyrighted by the AAO’s H. Dunbar Hoskins Jr., MD, Center for Quality Eye Care (see terms of use).