The MIPS Performance Report summarizes MIPS and Non-MIPS quality measure data by Physician/Physician Group Taxpayer Identification Number (TIN), so that physicians can monitor their performance throughout the year before submitting measures to CMS.
The performance period for MIPS and non-MIPS measures generally refers to the calendar year of January 1st to December 31st. The performance period for quality measures should be taken into consideration to ensure capture of quality activation if a shortened timeframe is chosen. For more information on the performance period review measure specification documents.
Below is an explanation of each section and field available in the report.
Measure Score Type
Measures are grouped by Score Type and displayed at the top of each section
Proportion Measures are percentages calculated as the number of occurrences divided by the measured population.
Continuous Measures span a range of values, such as mean wait time for a population.
Measures are grouped by score type within each Physician Group TIN. All proportion measures are displayed first, followed by continuous measures.
Measure Description
Measure Descriptions have three components:
Measure Number is the CMS MIPS quality measure number. Non-MIPS measures have the prefix “ACRad” (e.g. ACRad 1) and MIPS measures have no prefix (e.g. 76).
Measure Title is the official title as determined by CMS for the reporting year.
Domain is the National Quality Strategy Domain for the measure.
Proportion Measure Performance Rate
Proportion measures are divided into two sections for fields related to the Performance Rate and Reporting Rate.
The Performance Rate includes the following fields:
Initial Patient Population is the number of patients at the physician practice who are relevant for the measure, based on exams submitted for MIPS and Non-MIPS measures to date. If you indicate that 100% of exams were submitted to the registry, when selecting measures to submit to CMS, the number of records that we received will be used as the reporting denominator. Otherwise, if you enter a number other than the number of records that we received, that number will be used for this field.
Performance Denominator represents the number of observations evaluated in the Performance Rate and is equal to the Reporting Numerator, also known as the “Data Completeness Numerator”, minus any Denominator Exceptions (see below).
Performance Numerator indicates the number of records for which the performance measure was met.
Performance Not Met is the number of observations that do not meet the numerator requirements.
Performance Rate is the Performance Numerator divided by Performance Denominator:
Proportion Measure Reporting Rate
The Reporting Rate section, on the right half of the page, demonstrates the completeness of data submitted for measurement and includes the following fields:
Denominator Exclusions remove patients from measurement when circumstances do not meet the criteria.
Denominator Exceptions remove patients from the Performance Rate calculation, but retain them in the Reporting Rate. CPT Category II code modifiers such as 1P, 2P and 3P quality-data codes, or equivalents referenced from the registry are available to describe medical, patient or system reasons for denominator exceptions and can be submitted to the registry. A denominator exception removes a patient from the performance denominator only if the performance numerator criteria are not met – i.e. only if the observation would lower the performance rate. This allows for the exercise of clinical judgement by the eligible clinician.
Note: For example, MIPS Measure 225 estimates how often mammography screening reminder systems are used. A patient may be an exception if the eligible clinician documents a clinical reason for not using the reminder system, such as further screening exams not indicated due to patient limited life expectancy. However, the patient still counts towards the Reporting Rate.
Reporting Denominator is the number of “eligible instances” for which the measure could be reported. It may equal the Initial Patient Population if there are no Denominator Exclusions.
Reporting Numerator includes the total number of observations, minus any Denominator Exclusions, submitted with complete information.
Reporting Rate, also known as Data Completeness, is calculated as the Reporting Numerator divided by the Reporting Denominator. Denominator Exceptions are included in the Reporting Numerator, to give the physician credit for reporting data.
This rate needs to be at least 60% for successful MIPS participation.
Continuous Measures
Continuous Measures appear in a separate section and calculate performance scores for which each individual value for the measure can fall anywhere along a continuous scale. Continuous Measures can be aggregated using a variety of methods such as the calculation of a mean or median (for example ACRad 15 which looks at mean Radiography report turnaround time in hours) and are available for several ACR-defined Non-MIPS measures.
The following fields appear in the report:
Initial Patient Population defines the set of patients to be evaluated for the measure, in the same manner described above for Proportion Measures.
Measure Population defines the set of patients to be reported at the end of the performance period. The initial patient population and measure population numbers will be the same if the registry has all exams/cases submitted for the year.
Measure Exceptions remove patients from the Performance Score calculation. Reasons include removal of statistical outliers as well as measure-specific criteria for excluding patients from measurement.
Performance Score is the measure calculation, as defined for each measure. The Type, Unit, and Score Type fields provide context for the score being calculated.
Type describes what is being measured – e.g. time, dose.
Unit denotes the units of the measurement – e.g. hours, mGy.
Score Type describes the calculation made using the Measure Population - e.g. median, mean, etc.
Other Fields
The Selected for CMS Submission column indicates whether you have selected this measure for MIPS reporting to CMS. You may change which measures are selected at any time before final submission to CMS.
The following general notes may appear below the table for each measure:
CMS Benchmarks provide statistical context for MIPS Measures using data gathered by CMS. These are the benchmarks CMS will use when scoring measures. Benchmarks are displayed in deciles; benchmarks with fewer than 10 deciles indicate historical performance was skewed such that meaningful distinctions and improvement in performance cannot be made.
Registry Benchmarks provide statistical context for Non-MIPS Measures using data gathered by the NRDR QCDR, such as measures that may be reported to CMS from the DIR, for example.
Inverse measures denote measures for which a lower Performance Rate indicates better clinical care or control.
Note: Work is underway to highlight which measures are deemed “High Priority” by CMS.
There are other notes applicable to specific measures. If there are multiple notes for a measure, each is separated by a semicolon.
