• MIPS 2018—Quality: Report at Least 6 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 2018; also see the Academy’s MIPS hub page


    The Academy has developed QCDR quality measures to augment the standard MIPS quality measures.

    If you are reporting individual quality measures by claims, the IRIS Registry (via EHR integration or manually via the web portal), or your EHR vendor, here’s how you can maximize your score for the quality performance category. 

    Report at least 6 quality measures. Your score for the quality performance category will be based on your performance rates for up to 6 quality measures, plus high-priority and CEHRT bonus points, and—new this year—your quality category improvement percent score.

    Select your quality measures. The measures available to you will depend on your choice of reporting mechanism. To learn which measures are available for each reporting mechanism, see Tables 11 and 12 (PDF), or review the online listings. Use these tables to check whether measures lack benchmarks or are topped out; either of those situations could make it harder to get a high achievement score for quality.

    At least 1 quality measure should be an outcome measure. A measure that is listed as an intermediate 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, and care coordination measures.

    A note about terminology. CMS treats outcome measure as first among equals and although it lists them as 1 of 6 types of high-priority measure, it often refers to them as if they are distinct from high-priority measures (e.g., “include 1 outcome or high priority measure”).

    What if you can’t report on 6 quality measures? If 6 quality measures aren’t available, CMS expects you to report on as many measures as are applicable via your chosen reporting option.

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    Previous: Quality: You Can Report on 2 Types of Quality Measure.

    Next: Quality: When You Have Fewer Than 6 Measures That You Can 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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