• Table: Reporting 2021 MIPS Quality Measures via IRIS Registry–EHR Integration

    This content is excerpted from EyeNet’s MIPS 2021; also see the Academy’s MIPS hub page.


    Table: Reporting Quality Measures via IRIS Registry–EHR Integration

    Update: On June 11, CMS announced corrections to its benchmarks for almost all quality measures. For those reporting via IRIS Registry–EHR integration, this resulted in a change to the scoring summary for measure IRIS6. For almost all quality measures, the updated benchmarks make it harder to score highly. (The exceptions are measures with flat benchmarks, which remain unchanged.) 

    Read the tips on interpreting this chart.

    Meet two data submission thresholds. If your reporting for a quality measure satisfies both the case minimum requirement (20 patients) and the data completeness criteria (70% of denominator-eligible patients), your performance rate will be compared against a benchmark (if the measure has one), and you can earn the achievement points indicated below (see column 3).

    Understand the measures. Detailed measure specifications are available via the IRIS Registry dashboard. You also download these PDFs from the 2021 Clinical Quality Measure Specification and Benchmark Table at aao.org/medicare/quality-reporting-measures.

    Important caveat: You can only report a measure if the relevant data elements are available for extraction from your EHR system. Check with IRIS Registry staff to work on mapping for any of these measures.

    ID: Measure Name High-Priority Measure (Bonus Points) Achievement Points Notes

    Preventive Health Measures

    110: Preventive Care and Screening: Influenza Immunization   No benchmark  
    111: Pneumonia Vaccination Status for Older Adults   3-10 points  
    117: Diabetes: Eye Exam   3-10 points  
    128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan   3-10 points  
    130: Documentation of Current Medications in the Medical Record Patient safety (+1 point) 3-7 points

    Topped out measure, 7-point cap

    226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention   No benchmark  
    236: Controlling High Blood Pressure Intermediate outcome (+2 points) 3-10 points
    238: Use of High-Risk Medications in Older Patients Patient safety (+1 point) No benchmark Inverse measure
    318: Falls: Screening for Future Fall Risk Patient safety (+1 point) 3-10 points  
    374: Closing the Referral Loop Care coordination (+1 point) 3-10 points  

    Resource Use and Opioid Management

    IRIS26: Avoidance of Routine Antibiotic Use Before or After Intravitreal Injections Efficiency (+1 point) No benchmark Inverse measure
    IRIS52: Postoperative Opioid Management Following Ocular Surgery Opioid-related (+1 points) No benchmark

    Cataract/Anterior Segment

    191: Cataracts: 20/40 or Better Visual Acuity Within 90 Days Following Cataract Surgery Outcome (+2 points) 3-10 points  
    IRIS54: Complications After Cataract Surgery Outcome (+2 points) No benchmark Inverse measure
    IRIS59: Regaining Vision After Cataract Surgery Outcome (+2 points) No benchmark
    Also see IRIS55 and IRIS60, under “Glaucoma.” 

    Cornea/External Disease

    IRIS1: Endothelial Keratoplasty: Postoperative Improvement in Best Corrected Visual Acuity to 20/40 or Better Outcome (+2 points) 3-10 points  
    IRIS38: Endothelial Keratoplasty: Dislocation Requiring Surgical Intervention Outcome (+2 points) No benchmark Inverse measure
    Also see IRIS52 under “Resource Use and Opioid Management.”

    Glaucoma

    12: Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation   3-10 points  
    IRIS2: Intraocular Pressure (IOP) Reduction Intermediate outcome (+2 points) No benchmark  
    IRIS39: IOP Reduction Following Trabeculectomy or an Aqueous Shunt Procedure Outcome (+2 points) No benchmark  
    IRIS43: IOP Reduction Following Laser Trabeculoplasty Outcome (+2 points) 3-10 points  
    IRIS44: Visual Field Progression in Glaucoma Outcome (+2 points) 3-10 points Inverse measure
    IRIS55: Visual Acuity Improvement Following Cataract Surgery and Minimally Invasive Glaucoma Surgery Outcome (+2 points) No benchmark
    IRIS60: Visual Acuity Improvement Following Cataract Surgery Combined With a Trabeculectomy or an Aqueous Shunt Procedure Outcome (+2 points) No benchmark

    Neuro-Ophthalmology

    IRIS56: Adult Diplopia: Improvement of Ocular Deviation or Absence of Diplopia or Functional Improvement Outcome (+2 points) No benchmark
    IRIS57: Idiopathic Intracranial Hypertension: Improvement of Mean Deviation or Stability of Mean Deviation Outcome (+2 points) No benchmark

    Oculofacial Plastics/Reconstructive

    IRIS5: Surgery for Acquired Involutional Ptosis: Patients With an Improvement of Marginal Reflex Distance (MRD) Outcome (+2 points) No benchmark  
    IRIS6: Acquired Involutional Entropion: Normalized Lid Position After Surgical Repair Outcome (+2 points) 3-6.9 points or, with a 100% performance rate, 10 points  
    Also see IRIS52 under “Resource Use and Opioid Management.”

    Pediatric Ophthalmology and Strabismus

    IRIS48: Adult Surgical Esotropia: Postoperative Alignment Outcome (+2 points) 3-10 points  
    IRIS49: Surgical Pediatric Esotropia: Postoperative Alignment Outcome (+2 points) No benchmark   
    IRIS50: Amblyopia: Interocular Visual Acuity Outcome (+2 points) 3-10 points  

    Refractive Surgery

    IRIS23: Refractive Surgery: Patients With a Postoperative Uncorrected Visual Acuity (UCVA) of 20/20 or Better Within 30 Days Outcome (+2 points) 3-10 points  
    IRIS24: Refractive Surgery: Patients With a Postoperative Correction Within ± 0.5 Diopter (D) of the Intended Correction Outcome (+2 points) No benchmark  

    Retina/Vitreous

    Retina: Age-Related Macular Degeneration (AMD)
    IRIS45: Exudative AMD: Loss of Visual Acuity Outcome (+2 points) No benchmark  
    Also see IRIS26, under “Resource Use and Opioid Management.”
    Retina: Diabetic Retinopathy (DR) and Diabetic Macula Edema (DME)
    19: Diabetic Retinopathy: Communication With the Physician Managing Ongoing Diabetes Care Care coordination (+1 point) 3-10 points  
    IRIS13: Diabetic Macular Edema: Loss of Visual Acuity Outcome (+2 points) 3-10 points  
    IRIS58: Improved Visual Acuity after Vitrectomy for Complications of Diabetic Retinopathy Within 120 Days Outcome (+2 points) No benchmark
    Retina: Epiretinal Membrane
    IRIS41: Improved Visual Acuity After ERM Treatment Within 120 Days Outcome (+2 points) No benchmark  
    Retina: Macular Hole
    IRIS46: Evidence of Anatomic Closure of Macular Hole Within 90 Days After Surgery as Documented by OCT Outcome (+2 points) No benchmark  

    Uveitis/Immunology

    IRIS17: Acute Anterior Uveitis: Post-Treatment Grade 0 Anterior Chamber Cells Outcome (+2 points) No benchmark
    IRIS35: Improvement of Macular Edema in Patients With Uveitis Outcome (+2 points) No benchmark  
    IRIS51: Acute Anterior Uveitis: Post-Treatment Visual Acuity Outcome (+2 points) No benchmark  
    IRIS53: Chronic Anterior Uveitis: Post-Treatment Visual Acuity Outcome (+2 points) No benchmark

    Tips on Using This Chart

    This chart shows the benchmarks for quality measures reported via IRIS Registry–EHR integration . You also can report quaity measures manually via the IRIS Registry and, if in a small practice, via Medicare Part B claims.

    Column 1—ID: Measure Name

    Which measures should you report? Skim through this chart to see which measures you are most likely to (a) satisfy the case minimum requirement of 20 patients, (b) satisfy the 70%-data completeness criteria, and (c) achieve a high performance rate.

    Other factors to keep in mind are that:

    • you need to report at least one outcome or intermediate outcome measure (or if neither of those are available to you, some other type of high-priority measure);
    • you can earn bonus points for reporting additional high-priority measures (see column 2);
    • you should watch for measures where scoring stalls before the 10th decile—especially if they stall at a low decile (see column 3);
    • you should watch for measures that are subject to a 7-point cap (see column 4); and
    • you should be mindful of measures that don’t yet have a benchmark (see column 3).

    Column 2—High-Priority Measures (Bonus Points)

    Report at least one outcome measure. Report at least six quality measures, and at least one of them should be an outcome measure or an intermediate outcome measure (or if none is available, you must report another type of high-priority measure). 

    Earn high-priority bonus points. After reporting the initial, mandatory outcome or other high-priority measure (see above), you earn bonus points for submitting additional high-priority measures.

    Column 3—Achievement Points

    For some quality measures, you can earn 3-10 achievement points. Your score will depend on how your performance rate compares against a measure’s benchmark, which is split into deciles. If your performance rate falls within the benchmark’s 10th decile, you earn 10 achievement points; if it falls within the benchmark’s ninth decile, you earn 9.0-9.9 achievement points, depending on where it falls within that benchmark; if it falls within the benchmark’s eighth decile, you earn 8.0-8.9 achievement points; etc.

    Why does scoring for a measure start at 3 points? Provided you satisfy the 70%-data completeness criteria for a measure, there is a floor of 3 achievement points for reporting that measure. Thus, if your performance rate fell below the performance rate associated with the third decile, you would earn 3 achievement points. (If you didn’t satisfy the 70%-data completeness criteria, you would earn 3 achievement points if you are in a small practice, 0 points if you are in a large practice.)

    Why does scoring for some measures peak at 7 points? Some quality measures are subject to a 7-point cap.

    Scoring for some quality measures temporarily “stalls” before the 10th decile. The benchmarks for some quality measures approach perfect performance before the 10th decile. For example, measure IRIS6 has a benchmark that reaches a performance rate of 99.99% at the seventh decile. Consequently, if your performance rate is 99.99%, you would only earn 7.9 achievement points; however, a performance rate of 100% would earn you 10 achievement points (the chart indicates this in the “Achievement Points” column, by noting “3-7.9 points or, with a 100% performance rate, 10 points”). Some measures with stalled scoring also are subject to the 7-point cap, meaning that a performance rate of 100% would only earn you 7 achievement points.   

    What if a quality measure doesn’t yet have a benchmark? CMS used 2019 performance data to try and establish 2021 benchmarks for quality measures. If there isn’t enough 2019 performance data to establish a reliable benchmark for a measure, or if the measure didn’t exist in 2019, CMS will try to establish a benchmark retroactively using 2021 performance data. If it is still unable to establish a benchmark for a measure, you won’t be able to earn more than 3 achievement points for reporting that measure.

    Different benchmarks for different collection types. This chart refers to the benchmarks that would be used if you are reporting via IRIS Registry–EHR integration. There are other benchmark charts to review if you are reporting manually via the IRIS Registry or via Medicare Part B claims.

    Column 4—Notes

    What are inverse measures? An inverse quality measure is one where you earn more achievement points for a lower performance rate. (Example: Measure 1: Diabetes: Hemoglobin A1c Poor Control [>9%].)

    What is the 7-point cap? Once a quality measure is in its second year of being topped out, you won’t be able to score more than 7 achievement points for it.

    What is a flat benchmark? A flat benchmark is not based on performance data. Instead, it is based on a simple formula: A performance rate of 90% or more earns you 10 achievement points; a performance rate of 80%-88.9% earns you 9 achievement points, etc. For inverse measures that have a flat benchmark, such as measure 1, a performance rate of 10% or less earns you 10 achievement points, a performance rate of 10.1-20% earns you 9 achievement points, etc.

    What are topped out measures? CMS considers a measure to be topped out when a lot of clinicians are attaining, or almost attaining, maximum performance for that measure (e.g., the average performance rate is 95% or higher).

    Topped out measures have a limited life cycle. If a measure is topped out for at least two years, it is subject to a 7-point cap; topped out for three consecutive performance years, CMS will consider eliminating it in the fourth year. 

    What are extremely topped out measures? If CMS considers a measure to be extremely topped out (e.g., the average performance rate is 98% or higher), it can be removed from MIPS the following year, even if it hasn’t been topped out for three consecutive years. (Note: Topped out QCDR measures also are on an accelerated timetable for removal from MIPS, even if they aren’t extremely topped out.)

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    Next: Table: Reporting 2021 MIPS Quality Measures Manually via the IRIS Registry

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