Using the 2021 Clinical Quality Measure Specification and Benchmark Table
If you're submitting data for the Merit-Based Incentive Payment System (MIPS), you'll first need to determine which reporting mechanism you’ll be using.
After you've decided, review the measures available on the table below for that reporting mechanism (you’ll want to report at least six). The more measure achievement points you earn, the more likely you are to avoid any penalty.
- On the first pass of this chart, pick as many measures that allow you to earn up to 10.0 measure achievement points without any gaps (no stalled measures and no capped measures).
- Make sure at least one of them is classified as outcome or intermediate outcome.
- On your second pass, check if high-priority bonus points are available (you can earn up to a maximum of six). Earn these points is by reporting additional outcome measures, or selecting patient safety, efficiency, and care coordination measures. See the EyeNet®'s MIPS 2021 Primer and Reference tables for EHR integration, manual web entry and claims-based reporting.
- On your third and final pass, if reporting through IRIS Registry®-EHR integration or manual web entry, consider reporting IRIS QCDR measures that are without benchmarks in addition to your main selection. If you choose to report them, you will be assisting with the benchmarking for future years. This will give ophthalmic practices a greater selection of measures that reflect their everyday practice and can provide potentially more points than many other MIPS measures that are topped out.
3 Key Points
- To earn achievement points based on your performance rate, you must first meet the two data submission thresholds. When selecting quality measures, look for measures where you are most likely to a) satisfy the case minimum of 20 patients, b) satisfy the 70% data submission threshold, and c) achieve a high performance rate.
- Make sure you’re using the current version of this chart. If you’ve printed this table, always check aao.org/medicare/benchmarks in order to make sure you’re using the most current version. Otherwise take advantage of the table’s electronic version for live links, including those in column 2 for the measure specifications. Remember, the specifications vary depending on which reporting pathway you are using.
- Check your data mapping. If you are reporting via IRIS Registry - EHR integration, you can only report a measure if the relevant data elements can be extracted from the EHR system. There is a June 1 deadline to select measures for data mapping, and Sept. 30 is the last day to request mapping refinements for those measures. If mapping is successful, you should check your mapping regularly throughout the year.
Based on the Centers for Medicare & Medicaid Services 2021 Quality Benchmarks created 12/31/2020, 2021 Clinical Quality Measure Specifications and Supporting Documents, created 12/28/2000, 2021 Medicare Part B Claims Measure Specifications and Supporting Documents found at the QPP Resource Library https://qpp.cms.gov/resources/resource-library, accessed 12/31/2020, and 2021 Eligible Professional/Eligible Clinician eCQMs found at the eCQI Resource Center, https://ecqi.healthit.gov/ep-ec?qt-tabs_ep=1, accessed 12/31/2020.
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