This content was excerpted from EyeNet’s MIPS 2018; also see the Academy’s MIPS hub page.
CMS expects you to report on 6 quality measures. When determining your quality performance category percent score, CMS takes the sum of your quality measure achievement points and quality measure bonus points and then divides that by a denominator—CMS calls this denominator the total available measure achievement points—which is typically 60 points (or 70 points, in the unlikely event that the ACR measure applies; see The All-Cause Hospital Readmission Measure for Larger Practices).
But if you reported fewer than 6 quality measures via a qualified registry or via claims, CMS will apply a validation process—the eligible measure applicability (EMA) process—to determine whether you could have reported additional quality measures. If CMS determines that you could not have reported more measures, it reduces he denominator accordingly. For example, if you are only able to report 3 measures and the ACR measure doesn’t apply, then the denominator would be 30.
CMS doesn’t use a validation process for clinicians who report fewer than 6 measures via EHR-based reporting; CMS states that if you don’t have enough measures to report via EHR, you should use a different reporting mechanism.
CMS also isn’t establishing a validation process for QCDR reporters because it assumes that the QCDR will provide you with enough applicable measures; the Academy has urged CMS to rethink this policy.
Note: CMS expects you to report on measures that are applicable and available via your chosen reporting option. CMS defines applicable to mean “measures relevant to a particular MIPS eligible clinician’s services or care rendered.”
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