Select and Finalize MIPS Quality Measures for CMS Submission
Modified on: Fri, 9 Mar, 2018 at 5:28 PM
The Quality section of the CMS Submission 2017 page allows you to select and review the measures you want the ACR to submit to CMS. Click anywhere on the section header to expand the section.
Quality measures are grouped by Physician Group TIN. Group Practice Reporting Option (GPRO) TINs are marked with (GPRO) in the header, and Non GPRO TINs are labeled Individuals as determined by your selection in the GPRO section.
You may choose to use measure data for the full performance year or 90 days. If you choose to use 90 days, only data from October – December 2017 will be used.
You can download a copy of measure data for a TIN by clicking on the green Excel icon in the TIN section header.
To select a measure, click the box next to My group is selecting this measure for MIPS reporting.
Next, indicate whether the number of exams submitted represents all of the relevant exams for the year or, if not, then what the actual total was for the year. Click Save to save your selections. Summary information from the Performance Report tab then appears for the selected measure, with the Performance Rate and Completeness metrics shown on the right side of the screen. If the measure can be reliably scored against a benchmark, the decile in which the Performance Rate falls is shown.
Note: The decile indicates the lower bound on the number of points for the measure. The actual number of points will depend on where the Performance Rate falls within the decile.
A measure without a benchmark receives only 3 points; however, CMS will attempt to create a benchmark using measures from the 2017 performance year, so the final number of points may be higher. See Quality Performance Scoring for more details.
Note: To help maximize your score, you can select more than the minimum measures required and CMS will calculate your maximum Quality score based on the measures you submit. Submitting extra data also helps CMS create future benchmarks with deciles more reflective of actual performance. See Quality Performance Scoring for details.
Once you have selected a measure and saved your changes, the selection will be reflected in the Performance Report tab the following day.
Enter your e-mail address and click the Finalize button to indicate selected measures are ready to be submitted to CMS. You may want to do a final review of your measures, using the Performance Report, to validate all data are present and correct.
Quality measures will not be submitted for a TIN (GPRO) or physician NPI (Non GPRO) until you have both finalized your measure selections and completed the Attestation section to authorize the ACR to submit on your behalf.
The ACR will begin submitting all attested and finalized measures in March, 2018. Once finalized, you may still make changes to your selected measures at any time up until March 31. To do so, click the Undo Finalize button, make your changes and click the Save button for each measure you change, and click Finalize to indicate measures should be resubmitted to CMS.
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