Overview
CMS introduced the MIPS quality performance category to evaluate the quality of care delivered by measuring healthcare processes, outcomes, and patient experiences of care.
For the 2024 performance year, the quality category accounts for either 30% or 55% of the overall MIPS Performance score, depending upon whether a clinician or group qualifies for re-weighting the Promoting Interoperability (PI) category. For those who qualify for re-weighting, such as non-patient-facing clinicians, the PI weight of 25% is added to the base 30% weight for quality, bringing the overall quality category weight to 55%. See PI Performance Category Requirements for more information.
For the 2024 reporting year, MIPS-eligible clinicians have options for the quality performance category, including
deciding to participate individually, as a group or as a virtual group;
choosing which data submission mechanism to use.
Individual, Group and Virtual Group Participation
MIPS-eligible clinicians can participate individually, as a group, or as a virtual 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) 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.
Virtual group participation means solo practitioners and groups of 10 or fewer clinicians can come together "virtually" (regardless of specialty or location) to participate in MIPS for a performance period of a year. A virtual group identifier number will be assigned to the group and each clinician will be assessed and scored as a group. Virtual groups must aggregate their data across the virtual group for each performance category.
Data Submission Mechanisms
Clinicians have multiple options for submitting data:
Method | How it Works | Ind. | Group | Virtual 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 | Yes |
Qualified Registry (QR) | 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 | Yes |
Electronic Health Record (EHR) | Clinicians submit data to CMS directly through their EHR system or a qualified health IT vendor submits the data for them. | Yes | 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 exclusionhappened. | Yes | No | 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 2019 reporting year, registration is April 1 through June 30, 2018. | No | Yes | Yes |
Quality Measures and Requirements
For radiology, 54 MIPS and 12 QCDR quality measures are available for the 2024 performance year. See the article MIPS and QCDR Measures and Specifications for details. The measures are grouped into three classifications:
Process measures show what doctors and other clinicians do to maintain or improve health 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
Intermediate Outcome
Appropriate use
Patient experience
Patient safety
Efficiency
Care coordination
To meet the full-year quality requirements, clinicians must
Report at least 6 measures (or a complete specialty measure set) for at least 75% of the eligible provider’s applicable patients seen from January 1 through December 31.
Note: For Claims reporting, applicable patients are Medicare patients. For QCDR reporting, applicable patients include all payers.
Report on at least one outcome measure. If one outcome measure is unavailable, 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, CMS triggers the Eligible Measure Applicability (EMA) process to investigate if other measures 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.
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 benchmarked.
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 60 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, you’ll get 3 points for the measure during year 3. 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.
Score improvement: Clinicians can receive bonus points in 2024 if the Quality performance category score improves from 2023.
Quality measures that do not meet data completeness requirements (75%) will receive 1 point; small practices consisting of fewer than 15 clinicians will receive 3 points. If you don’t submit at least 1 available measure, you will not receive any points in the Quality category. Clinicians also have the opportunity to raise their Quality category score based on improvement from the prior calendar year (CY) of Quality category reporting.
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.
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 improving performance on both MIPS and/or QCDR 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.
How does CMS evaluate eligibility for improvement scoring?
Clinicians will be evaluated for improvement scoring in 2024 using the following:
Have a Quality performance category achievement % score based on reported measures for the last performance period (calendar performance year) and the current performance period;
Participate fully in the Quality category for the current performance period (submit 6 measures/specialty measure set with at least 1 outcome/high priority measure OR submit as many measures as were available and applicable; all measures must meet data completeness requirements);
Submit data under the same identifier for the 2 performance periods
