iPatientCare Blog - Maximizing your Quality Performance Category Score

Getting the Most out of MIPS Part 1: Maximizing your Quality Performance Category Score

MIPS (Merit-based Incentive Payment) is one of the pathways under MACRA Quality Payment Program which streamlines multiple quality reporting programs and provides payment adjustments to eligible clinicians based on their performance across four performance categories – Quality, Cost, Improvement Activities, and Advancing Care Information. Cost Category is not being scored in 2017. In this 3 part series, we will explore the performance categories and how to optimize your score in each of the categories.

Quality is one of the four performance categories for MIPS and accounts for 60% of the Composite MIPS Score for 2017. It replaces PQRS (Physician Quality Reporting System). If Quality is not scored, the weightage would be redistributed as 50% to Improvement Activities and 50% to Advancing Care Information.

You need to submit at least 6 measures including an outcome measure or a high priority measure in absence of an outcome measure for 50% of the patients for a period of 90 days. You can select either individual measures or a specialty set. For groups of 16 or more clinicians, and additional All-cause hospital readmission measure will be calculated from Claims if they meet the minimum case volume of 200 cases.

  • Participation Option: You can participate as an individual or group. Group means a single TIN with 2 or more NPIs who have reassigned their Medicare billing rights to the TIN. For group submission, you have to aggregate the performance score for all the clinicians in the TIN. Groups in MIPS APM should report through their APM.
  • Data Submission Options: Quality Performance Category can be submitted through Claims, Certified EHR, MIPS qualified Registry, or MIPS qualified QCDR. Groups of 25 or more can additionally submit through the CMS web interface. Groups using the CMS web interface would have to report on all 15 measures for the full year. A Group of 2 or more eligible clinicians can report for the CAHPS for MIPS survey. CAHPS for MIPS survey counts towards a high priority measure in absence of another outcome or high priority measure. It is also a high-weighted improvement activity. CMS web interface and CAHPS for MIPS survey require registration with CMS prior to 30th June.
  • Data Completeness Criteria: For claim-based submissions, the data completeness criteria is 50% of Medicare Part B patients. For submissions through EHR, Qualified Registry, or QCDR, you have to submit data for a minimum of 50% of patients regardless of payers and include at least one Quality measure for one Medicare patient.

How Quality Scored is:

  • Each of the measures submitted fetches 3-10 points based on the benchmark decile for that measure. Benchmarks are based on the national performance in a baseline period which is 2 years prior to the performance period.
  • If Benchmark does not exist for a measure, or the data submission does not meet the data completeness criteria of 50% of patients or the minimum case volume of 20; 3 points are awarded for that measure.
  • For submitting through CMS web interface, 0 points are awarded if the data completeness criteria are not met. If minimum case criteria are not met, or a benchmark does not exist, the measure will not be scored.
  • Failure to submit a measure results in 0 points for that measure.
  • Maximum possible points are 60 for small practices, 70 for groups of 16 or more clinicians who are scored on the hospital readmission measure, and 110 (or 120 points depending on whether the hospital readmission measure is scored) for reporting through the CMS web interface.
  • Bonus points, capped at 10% of the denominator are awarded for submitting additional high-priority measures, provided they meet the minimum case volume, data completeness requirement and have a performance rate greater than 0. 2 points, that are awarded for each additional outcome measure and 1 point for the high-priority measure.
  • Bonus points, capped at 10% of the denominator are awarded for each measure submitted using CEHRT for end-to-end electronic reporting.
  • You can submit more than 6 measures. If more measures are submitted, the best 6 would be used for calculating the score. Bonus points (if applicable) would be granted for each measure submitted and capped at 10% of the denominator.

Eligible Measure Applicability (EMA): Similar to the Measure-Applicability Validation (MAV) process of CMS, EMA is invoked if less than 6 measures are submitted, or no outcome or high-priority measures are submitted. EMA is applicable for Claims and Registry submission only and it verifies if at least 6 measures were available; f less than six were submitted or whether an outcome or high-priority measure was available if none were submitted. If EMA determines an applicable measure was available, the missing measure is scored 0, else the missing measure is removed from the denominator, and the score is based on the remaining measures.

Choosing the right Quality Measures:

  • Select more than 6 measures that are most relevant to your practice. That way you will have the option to choose the best 6 at the end of the year.
  • Ensure that you have at least one outcome measure.
  • If you have previously participated in PQRS or Meaningful use, those measures can serve as a great starting point.
  • For each of the measures:
    • Ensure that you meet the minimum case volume of 20.
    • Monitor your performance rate and map it to the published benchmark deciles for the appropriate submission method to calculate your points for that measure. The benchmarks for 2017 are available from https://qpp.cms.gov/docs/QPP_Quality_Benchmarks_Overview.zip. This will give you your points for that measure.
    • Determine the performance rate needed to increase the points to the next decile benchmark and work towards achieving it. Invest in an EHR (such as iPatientCare) that can provide you alerts to complete the required action for each of the measures prior to signing off a visit note.
    • Keep reviewing your performance periodically and track the performance improvements. Again EHRs like iPatientCare provides a real-time MIPS dashboard to track your score.
  • Other considerations while selecting the measures:
    • Different sets of measures are available for different submission methods and in 2017, you cannot combine different submission methods within a performance category. So ensure that all the measures you select are eligible for a single submission method.
    • Benchmarks differ for the same measure submitted through a different submission method. For example, for Measure ID 1: Diabetes: Hemoglobin A1c (HbA1c) Poor Control, a performance rate of 7% would fetch you a score of 8 if you submit through EHR, 9 points on claim submission, and full 10 points if you submit through a Qualified Registry or QCDR. If your measures are supported by multiple submission methods, consider the method which fetches you higher points.
    • See if you can include more outcome measures or high priority measures. They will fetch you bonus points.
    • If your EHR is capable of electronic submission to CMS, consider using EHR for an end-to-end submission bonus.
    • If submitting through your EHR, verify whether the EHR is certified for all the measures selected by you. You can check that out from the CHPL website (https://chpl.healthit.gov).
    • If submitting through Qualified Registry or QCDR, select a Qualified Registry or QCDR which are qualified for your chosen measures. The list of the qualified registries and QCDRs is available at https://qpp.cms.gov/docs/QPP_2017_Qualified_Registries.pdf and https://qpp.cms.gov/docs/QPP_2017_CMS_Approved_QCDRs.pdf respectively.
    • Avoid topped-out measures. They may be removed in the future.
    • Avoid measures without benchmarks. They will fetch you only 3 points even if you have a high-performance rate.
    • The performance will be published on the Physician Compare website. So select the measures where you score really well and that show you in a good light compared to your peers rather than selecting a measure simply to avoid the penalty. (For 2017, then pick your pace option allows you to report on only one Quality Measure for one patient to avoid the -4% payment adjustment in 2019)

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About the Author:

Arnaz Bharucha is the R&D Lead for Quality Improvement and Senior Software Architect with over 17 years of experience in designing and supporting healthcare IT products for Electronic Health Records, Quality Reporting for MIPS, Meaningful Use, PQRS, PCMH, DOQ-IT, etc., and professional & institutional medical billing systems. She has shouldered key responsibilities of understanding the US Healthcare industry standards, designing iPatientCare suite of products in compliance with the ONC’s Meaningful Use, designing and implementing interoperability, and other healthcare Quality Reporting initiatives requirements. Under her leadership, iPatientCare has been a Qualified Registry for submitting quality measures to CMS since 2014.


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