The Interactive Quality Measures report provides both summary and detailed information about the quality measures available for CMS reporting for MIPS.

Note: This report is best viewed in Full Screen mode.



Report Filters

The following filters and parameters allow you to refine the data displayed across all report charts and tabs

  • Use the View By parameter to select whether to view measures by TIN or by individual Provider/NPI

  • The Year filter has two options for 2017: 90 days and Full Year

  • There are separate filters for TIN and for Provider Name and NPI

MIPS Measure Summary Pie Chart


Note: The NPI filter is populated only when the View By parameter is set to NPI.


There are three report tabs available with various tables and charts, as described, below.



MIPS Dashboard

The MIPS Dashboard is the main view and summarizes data into three charts.


The TIN/NPI Measure Summary displays the total number of measures by status category across all TINs/NPIs.


There are five status categories:

Status

Definition

Next Steps

Insufficient Data

The measure does not meet the minimum reporting criteria, as defined by CMS. For example, for 2018, a measure must have at least 20 cases reported and a Reporting Rate of at least 60%.

Make sure you have reported all possible exams for all patients, including non-Medicare patients.

Insufficient Data, No Historical Benchmark Available

The measurement does not meet the minimum reporting criteria AND there is no historical benchmark currently available from CMS.

Report additional cases, if possible.

Reporting Eligible, No Historical Benchmark Available

The measure does meet reporting criteria and is available for reporting to CMS, but there is no historical benchmark currently available.

You can still choose the measure for reporting, but you will receive only the minimum points unless a benchmark is created by CMS later in the year.

Reporting Eligible, with Benchmark

The measure meets reporting criteria and a benchmark is available.

Select the measure for CMS reporting.

Selected for CMS

The measure meets reporting criteria, has been benchmarked, and has been selected for reporting to CMS.

Select and finalize your quality measures for CMS submission.


The Measure Counts bar chart provides the next level of detail with counts of measures in each status category for each TIN or NPI so that you can identify where additional data may be needed to meet reporting criteria.MIPS Measure Counts Bar Chart


The MIPS Measures Deciles is a visual representation of benchmarked measures, with Deciles on the y-axis and measures on the x-axis.

MIPS Measure Deciles Scatterplot

This chart can help identify patterns such as measures with lots of low deciles or providers with below-average measures. See Interactive Features, below, for how to navigate the data in this chart.



Quality Performance Summary

The Quality Performance Summary provides a high-level view of performance across all MIPS and QCDR measures for each TIN/NPI. The table shows performance scores for Continuous measures and performance rates for Proportional measures, to help identify patterns across measures and TIN/NPIs.MIPS Quality Performance Summary Table

You can download the data from this table by clicking the Download icon in the lower right corner.

Note: The Download icon is not available when viewing the report in Full Screen mode.



Quality Measure Detail

This table provides the most detailed information about each measure for TINs/NPIs, using a format similar to the MIPS Performance Report. Measures falling below CMS reporting criteria are highlighted, with indicators in the Reporting Numerator column for measures with fewer than the CMS case minimum, and in the Reporting Rate column for measures with reporting rates below the CMS threshold.

MIPS Quality Measure Detail Table

The report has an additional Measure Status filter to restrict the table to specific status categories – e.g. if you want to show only measures with a status of Insufficient Data.



Interactive Features

There are a number of ways to drill down and highlight data, using the MIPS Dashboard, to gain insight into the data.

MIPS Measure Summary Pie Chart Link

Using the Measure Summary pie chart, you can identify all measures in a specific status category by hovering over a slice in the chart to display the See All Measures with This Status link. Clicking the link takes you to the Quality Measure Detail tab, which is automatically filtered to show only measures having the highlighted status. For example, clicking on the link in the chart to the left would display detailed data for all 19 measures with status Reporting Eligible, with Benchmark.


You can filter or highlight the MIPS Measure Deciles scatterplot using either the Measure Counts bar chart or the scatterplot legend. Clicking on a bar in the bar chart filters the scatterplot to show only those measures specific to the selected TIN/NPI. Remove the filter by clicking again anywhere on the chart.


Clicking on a TIN / Provider in the scatterplot legend performs a similar function, but rather than completely filtering the chart it highlights the selected TIN/NPI by making all other values fainter as in the example, below. You can also single-click on any mark in the scatter plot to highlight all measures for that TIN/NPI.

Measure Deciles Scatterplot Highlight


Hovering over a mark in the scatterplot displays additional details for that measure, including the measure name, performance score/rate, and CMS benchmark (if available).

MIPS Measure Decile Scatterplot Hover