Breaking down MIPS – Part 1: Quality category

MIPS QualityWhen it comes to the Quality Payment Program (QPP) and moving Medicare Part B clinicians to a performance-based payment system, most practices know by now that there are 2 tracks to choose from—Advanced Alternative Payment Models (APMs) or the Merit-Based Incentive Payment System (MIPS).  For 2017, MIPS has 4 performance categories, weighted as follows:

This blog post will focus on MIPS and the quality performance category.


Let’s review the basics of who can participate in the QPP. To qualify for the QPP you must bill more than $30,000 to Medicare Part B and provide care for more than 100 Medicare patients per year.  If you decide to participate in MIPS, you may earn a performance-based payment adjustment.

For MIPS you must also be a:

  • Physician
  • Physician assistant
  • Nurse practitioner
  • Clinical nurse specialist
  • Certified registered nurse anesthetist

You cannot participate in MIPS if:

  • You are newly enrolled in Medicare (2017 is your first year participating)
  • You are below the low-volume threshold
  • You participate in an advanced APM

You can choose to report as an individual or group. If you choose to report as a group, that means there are more than 2 clinicians whose individual NPIs have reassigned their billing rights to a single Tax Identification Number. Your data get aggregated and sent as the group.

The first performance period began January 1, 2017 and closes December 31, 2017. To potentially earn a positive payment adjustment under MIPS, you must send in data about the care you provided and how your practice used technology in 2017 to CMS by March 31, 2018 for a payment adjustment in 2019. If you have not yet gotten started, it’s time to pick your pace.

Reporting quality

The quality portion of MIPS—which accounts for 60% of the overall MIPS score—replaces the Physician Quality Reporting System (PQRS) and the quality portion of the value-based modifier.

As the largest performance category of MIPS, it is the one you’ll want to be most familiar with. In this transition year for the QPP, you can pick your pace, meaning that you can submit a minimum amount of data for one measure set for 2017 in order to test your system to determine if you need to make adjustments prior to reporting in 2018. Or you can do partial reporting, which means submitting at least 6 quality measures, including at least 1 outcome measure, between 90 days and a full year. Your third option is to report 6 measures, including the outcome measure, for the full performance year.

The quality portion of MIPS was created to add some flexibility, focusing on the measures that are important to your practice. Each eligible clinician will select 6 of 300 available quality measures, which is a decrease from the previous program under PQRS, which had 9 measures covering  3 domains (CMS no longer requires the domain requirements for this new program). Of those 6 measures to report, one must be an outcome measure. If an outcome measure is not available, the clinician should select another high-priority measure, such as an appropriate use measure, patient experience measure, patient safety measure, efficiency measure, or a care coordination measure. You may also select specialty-specific measure sets.

Points for quality

As mentioned, within the quality performance category individual clinicians will need to select 6 measures to report. Clinicians receive a minimum of 3 points for reporting the range of measures, depending on the performance against the benchmark for the measure (visit the QPP website under education and tools to review the quality benchmarks for each measure). In year one of the QPP, participants automatically receive at least 3 points for simply completing and submitting a measure. So if you submit any measure, either under the test category or for the full year, the minimum points you would receive would be 3. If a measure cannot be reliably scored against the benchmarks, the clinician will still receive the minimum 3 points.

The quality category of MIPS determines your performance by comparing it to a national benchmark—noting how you stack up against everyone else in the country who reported on the same measure. The benchmarks for the quality component are separated by measure and are specific to the type of data-submission method (e.g., EHRs, QCDRs/Registries, CAHPS, and claims). It doesn’t matter if you report as an individual clinician or as part of a group; the benchmark will remain the same. To create benchmarks for each measure, CMS takes information that was reported via PQRS 2 years prior to the current performance year.  For CAHPS, benchmarks are set based on 2 surveys: 2015 CAHPS for PWRS and CAHPS for ACOs. Submissions via the CMS Web Interface will use benchmarks from the 2017 Medicare Shared Savings Program. For measures with no historic benchmark, CMS will attempt to calculate benchmarks based on 2017 performance data.

To summarize:

  • Select 6 of the 300 available quality measures (to report on for a minimum of 90 days)
    • Or a specialty set
    • Or CMS web interface measures
    • Readmission measure is included for group reporting with groups of at least 16 clinicians and sufficient cases
  • Clinicians will receive anywhere from 3 to 10 points on each quality measure based on performance against benchmarks. Each measure reported requires the following information:
    • Measure name and ID
    • Submission type (EHR, QCDR/Registry, claims)
    • Measure type (e.g., outcome, process)
    • Whether or not a benchmark could be calculated for that measure/submission mechanism
    • Whether the benchmark is topped out (i.e., not showing much variability and may have different scoring in the future)
  • Failure to submit performance data for a measure = 0 points

There are bonus points available for individual clinicians and those reporting for a group. Bonus points are awarded for:

  • Submitting an additional high-priority measure
    • 2 bonus points for each additional outcome and patient experience measure
    • 1 bonus point for each additional high-priority measure
  • Using CEHRT to submit measures to registries or CMS
    • 1 bonus point for submitting electronically end-to-end

Quality calculation

The maximum number of points an individual clinician can earn for the quality component of MIPS is 60. To calculate the total quality performance category score, add the points earned on the required 6 quality measures that you report, plus any bonus points that you receive, and divide it by 60.

It’s important to note that if you are a clinician for a group of 15 or more, the calculations are different. The maximum number of quality points available to groups of clinicians is 70. This is because those groups are also measured on the readmission measure, which is a CMS-calculated measure based on claims data. Groups of clinicians will only be measured with the readmission measure if they have more than 200 cases. So the maximum quality points are 70 for groups, which includes 6 measures plus 1 readmission measure.

CMS web interface reporter total score:

  • 120 points for groups with complete reporting and the readmission measure
  • 110 points for groups with complete reporting and no readmission measure

Other submission measure total score:

  • 70 points for 6 measures + 1 readmission measure
  • 60 points if a readmission measure does not apply

Are you ready? We are!

Quanum EHR is fully certified for the QPP based on 2014 Edition Certification and the associated CMS regulatory requirements. The QPP requires EHRs to advance to the 2015 Edition Certification by 2019, and Quanum EHR will be ready for that deadline. The Quanum EHR solution is prepared to support your practice with MIPS in 2017 and beyond. Read our MACRA brochure to learn more.

For more information on how the Quanum EHR can help you report, call 1.888.491.7900, or read our white paper, “3 things to know about making the EHR switch.”

Source:  CMS

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