The MIPS Quality performance category replaces and incorporates components of the Physician Quality Reporting System (PQRS) and the Physician Value-based Payment Modifier (VM). The goal of the Quality category is to help improve the quality of patient care by measuring health care processes, outcomes, and patient perceptions, and to use this data to provide feedback and incentives to clinicians.


For the 2017 performance year, Quality accounts for 60% or 85% of the overall MIPS Performance score, depending upon whether a clinician or group qualifies for reweighting the Advancing Care Information (ACI) category. For those who qualify, such as non patient-facing clinicians, the ACI weight of 25% is added to the base 60% weight for Quality, bringing the overall Quality weight to 85%. See ACI Performance Category Requirements for more information.


For the 2017 transition year, MIPS-eligible clinicians have options for the quality performance category, including

  • deciding to participate individually or as a group;

  • choosing how much data to submit, also known as “Pick Your Pace”; and

  • choosing which data submission mechanism to use.



Individual and Group Participation

MIPS-eligible clinicians have the option to participate individually or as a group.

  • Individual participation means a clinician receives payment adjustment and feedback based on their individual performance. The clinician is identified by their National Provider Identifier (NPI) which is tied to a Taxpayer Identification Number.

  • Group participation means each clinician in the group is evaluated equally, with payment adjustment and feedback aggregated and determined by the group’s performance. Reporting is done through a single group TIN, with at least two MIPS-eligible clinicians identified by NPI and who have reassigned their Medicare billing rights to the group TIN.



Pick Your Pace

Clinicians can choose from three participation levels for the transition year:

  1. Test allows clinicians to receive neutral or small payment adjustment by submitting just one measure from any category – e.g. just one quality measure or improvement activity.

  2. Partial Year participants can report for a 90-day period to qualify for a small positive payment adjustment.

    NoteMIPS participants using the ACR QCDR for a 90-day are limited to October 2, 2017 through December 31, 2017. Data may be submitted retroactively for participants registered by October 31, 2017.

  3. Full Year participants can qualify for a moderate positive payment adjustment by submitting data for the January – December 2017 performance year.

CMS Pick Your Pace



Data Submission Mechanisms

Clinicians have multiple options for submitting data:

   

   

Method

How it Works

Ind.

Group

Qualified Clinical Data Registry (QCDR)

A QCDR is a CMS-approved entity that collects medical and/or clinical data to track patients and disease. NRDR is a CMS-approved QCDR, with custom quality “Non-MIPS” measures specially developed for radiology.

Yes

Yes

Qualified Registry

A qualified registry collects clinical data and submits it to CMS on behalf of MIPS-eligible clinicians. Qualified Registries must be approved by CMS, and can only report MIPS measures defined by CMS.

Yes

Yes

Electronic Health Record

Clinicians submit data to CMS directly through their EHR system or a qualified health IT vendor submits the data for them.

Yes

Yes

Claims

Clinicians pick measures and report through their routine billing processes. If they choose this option, they need to add certain billing codes to denominator eligible claims to show that the required quality action or exclusion

happened.

Yes

No

CMS Web Interface

A secure internet-based application available to preregistered groups of 25 or more MIPS eligible clinicians. CMS partially pre-populates the CMS Web Interface with claims data from the group’s Medicare Part A and Part B beneficiaries who have been assigned to the group. Then, the group completes the clinical data for the pre-populated Medicare patients.



For the transition year, registration was April 1 through June 30, 2017.

No

Yes



Quality Measures and Requirements

For Radiology, there are 56 MIPS and 24 non-MIPS quality measures for the 2017 performance year, grouped into three classifications:

  • Process measures show what doctors and other clinicians do to maintain or improve health, either for healthy people or those diagnosed with a given condition or disease. These measures usually reflect generally accepted recommendations for clinical practice, such as the percentage of people getting preventive services, such as mammograms.

  • Outcome measures show how a health care service or intervention influences the health status of patients. For example, the percentage of lung cancer screenings interpreted as positive.

  • High priority measures include the following categories:

    • Outcome

    • Appropriate use

    • Patient experience

    • Patient safety

    • Efficiency measures

    • Care coordination


To meet Full Year requirements, clinicians must

  • Report at least 6 measures for at least 50% of the eligible provider’s applicable patients seen from January 1, 2017 thru December 31, 2017.

Note: For Claims reporting, applicable patients are Medicare patients. For Registry/QCDR reporting, applciable patients include all payers.

  • Report on at least one outcome measure. If one outcome measure is not available, then report on a high priority measure.

  • If an individual clinician or group decides to report fewer than the six required measures or if no outcome/high priority measure is reported, this will trigger the Eligible Measure Applicability (EMA) process so CMS can investigate and see if there are other measures that should have been reported.


CMS states: The EMA process is only used with claims or qualified registry data submissions. We don’t use the EMA for Qualified Clinical Data Registry (QCDR) and Certified Electronic Health Record Technology (CEHRT) submission. If you use QCDR or CEHRT to submit your quality data, we won’t check to see if the expected six quality measures should be reduced. Also, we won’t use the EMA for group quality category performance when you submit your data through the CMS Web Interface.


More information is available on the 2017 MIPS measures and QCDR (Non-MIPS) measures in Review Available Measures or you can navigate the MIPS Measure Calculator.



Quality Scoring

Based on your performance, you’ll get 3 to 10 measure points for each quality measure you submit if the measure can be reliably scored against a benchmark.


Note: Reliably scored means that:

  • A national benchmark exists

  • The case volume threshold has been met (>20 cases for most measures; >200 cases for readmissions)

  • At least 50 percent of possible data are submitted, meeting the data completeness requirement.


Not all measures will have a benchmark and many measures may be benchmarked based on the number of clinicians reporting that allow for the criteria above to be met from within the performance year - i.e. "same year benchmarks." If there’s no benchmark, then you’ll get 3 points for the measure during year 1. Everyone who reports, individuals and groups regardless of specialty or practice size, are combined in the calculation to derive each benchmark.


Bonus points are available for:

  • End-to-end reporting: Clinicians receive one bonus point if they report their quality data directly from their EHR to a qualified registry, QCDR, or via the CMS Web Interface.

  • Submitting additional measures: Clinicians can get one bonus point for each high priority measure and two bonus points for each additional Outcome and Patient Experience measure.


In the 2017 transition year, you’ll automatically get 3 points just for submitting 1 quality measure on 1 eligible patient at any time during the performance period. If you don’t submit at least 1 available measure, you will not receive any points in the Quality category.


Points are summed up across quality measures and added to any bonus points received, and then divided by the maximum number of points available for the clinician/group. The resulting score is then weighted and combined with other MIPS measures to create the overall MIPS score.MIPS Total Quality Performance Category Score


Note: For most radiology clinicians, the maximum number of points available is 6 measures x 10 points = 60 points.


Bonus points are capped at 10% of the maximum number of points – e.g. a clinician may get 6 bonus points if they have 60 maximum possible points (6 required measures x 10 maximum points per measure).


Radiologists can maximize their MIPS final score by focusing on improving performance on both MIPS and/or non-MIPS quality measures and submitting as many measures to CMS as possible. CMS will use all submitted measures to calculate the maximum Quality score. See MIPS Quality Performance Scoring for a detailed example.