Considerations Choosing MIPS Quality Measures · •Quality portion of MIPS composite score = 60...

Considerations for Choosing MIPS Quality Measures

July 2017

Overview of Contents

• First know yourself• Finding measures• Understanding scoring• Special Considerations – about registries• Special Considerations – ESRD patients• Understanding the data that feeds measures – numerators, denominators, and excluders – OH MY!

• Data capture in the typical workflow• Data quality and integrity• Notes and considerations on reporting • 2018 proposed CMS updates

RPA Guide to QPP Participation 2

First Know Yourself

Quality measurement is dependent on making sure you are choosing measures that:

• Reflect the most typical care you or your practice provide• Have reasonable distributions of performance (decile range benchmarks) so you can achieve high scores, even when you don’t have 100% performance

• Require data that your electronic health record system can easily and discretely record


Identifying and Choosing Measures• Library of Measures at qpp.cms.gov• 271 measures currently approved• Must know the requirements for complete data and choose the method of how you or your group want to submit data

• Important to remember that measures are benchmarked and earning a score is dependent on deciles of performance and the submission method.

• Decile of performance equals point score; e.g. 9th decile = 9 points

All tables adapted from http://healthcareblog.pyapc.com/2017/01/articles/pay‐for‐performance/optimizing‐your‐mips‐score‐quality‐measure‐benchmarks‐and‐reporting‐mechanisms/4

Scores for MACRA/QPP – MIPS Quality Category

• Quality portion of MIPS composite score = 60 (out of 100) points for 2017• Earning the 60 points is based on how well you (or your group) performs on the 6 chosen quality measures, where each measure is worth a maximum of 10 points.

• Groups of >16 clinicians will also be held accountable for a 7th measure –the AHRQ all cause hospital readmission measure. No reporting is required – data is aggregated and reported for you by CMS from claims data.

• There are bonus points achievable for choosing certain measures or using certified EHR technology (CEHRT).

• The 60 points of the MIPS composite score is the % of points out of 60 (or 70 for groups >16) earned.


Measure Measure Type

# of Cases

Performance Points

Bonus Points For

High Priority

Bonus Points for CEHRT use

Totals

Measure 1 Outcome

Measure using CEHRT

20 4.1 0 (required) 1 5.1

Measure 2 Process using CEHRT 21 9.3 N/A 1 10.3

Measure 3 Process using CEHRT 22 10 N/A 1 11

Measure 4 Process 50 10 N/A N/A 10

Measure 5 High Priority 43 8.5 1 N/A 9.5

Measure 6 Process below case minimum 10 3 N/A N/A 3

All‐Cause Hospital Readmissions Claims 205 5 N/A N/A 5

Total Points All Measures N/A 49.9 1 3 53.9

MIPS – Quality Measure Score Card Example• Group >16 clinicians, therefore 70 maximum possible points

• Did not meet the minimum # of reported cases for measure #6

• Earned bonus points for reporting via EHR and choosing high priority measures (#1,2,3, and 5)

• 53.9/70 = 77% Quality Category Score

• 77% of 60 possible MCS = 46.2 MIPS Composite Score Points

From MACRA final rule TABLE 19: Quality Performance Category Example with High Priority and CEHRT Bonus Pointshttps://www.federalregister.gov/documents/2016/11/04/2016-25240/medicare-program-merit-based-incentive-payment-system-and-alternative-payment-model-incentive-under

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Notes on Scoring of Measures• Score is based on the performance decile achieved according to published, benchmarked distribution.

• CMS publishes benchmarks for all measures on QPP.CMS.GOV

• Many measures are topped‐out, meaning there are very small performance differences separating the deciles.

• The same measure often has different benchmarks, depending on method of submission

• For 2017‐2018 EHR submission has the lowest percentage of topped out measures

All tables adapted from http://healthcareblog.pyapc.com/2017/01/articles/pay‐for‐performance/optimizing‐your‐mips‐score‐quality‐measure‐benchmarks‐and‐reporting‐mechanisms/7

Notes on Registries• Qualified Registries (QRs) are approved vendors that aggregate and report quality data on behalf of subscribing clinicians and practices. MIPSwizard is an example.

• QCDRs (Qualified Clinical Data Registry) are databases that allow the collection and submission of the data needed to report on quality measures.

• QCDRs differ from Qualified Registries (QRs) in that QCDRs will offer both standard quality measures as well as custom, CMS‐approved quality measures that are not available in standard MIPS library of measures published by CMS. These custom measures may be specific to a disease or specialty of medicine. RPA’s Kidney Quality Improvement Registry (a QCDR) is an example.

• Both QRs and QCDRs typically charge subscription fees and may offer various visualization and other tools, beyond simple data aggregation and reporting


Notes about ESRD patients

• At a minimum (and depending on how a clinician or group reports data), CMS requires reporting on 50% of Part B patients who fall in the denominator of a chosen measure.

• When choosing measures, the types of encounters (based on CPT code) and/or disease state based on (ICD‐10) will determine which patients count in the denominator.

• There are very few measures that include the dialysis CPT codes (909XX) or N18.6 in the denominator.

• However, if a chosen measure does include ESRD services or patients, how to capture other needed data for the measure on enough patients will have to be considered given that EHR system use and robust data capture are not as easy in the dialysis setting.

There is a lot of confusion about the ”requirements” for reporting across MIPS categories on ESRD patients.


Understanding the data that feeds measures –numerators, denominators, excluders, OH MY!

• For each chosen measure, it is important to ensure that for each data element required the following is known:• Where it is captured in the practice workflow?• Who is responsible for capturing it?• Which field‐specific data must be entered in the EHR?• What the acceptable range of responses are for each specific data element needed?


Example – Smoking Cessation – CMS #226 Preventative Care and Screening: Tobacco UseMeasure: Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user

Denominator Inclusion Numerator Inclusion Numerator Exclusion

Age > 18 on or after time of visit • reports no tobacco use

• NOT Screened for tobacco useand• circumstances document (terminal illness, etc.)

and or or

A patient encounter resulting in a CPT list defined by CMS*

*90791, 90792, 90832, 90834, 90837, 90845, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 97003, 97004, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99406, 99407, G0438, G0439

• Reports current tobacco use No Screening and/or no intervention for other documented reason

and or

• received counseling (3 min or less), pharmacotherapy, or both

No Screening and/or no intervention without documentation(measure not met)


Measure #226 Data Workflowand CPTsto be reported

From https://pqrs.cms.gov/dataset/2016‐PQRS‐Measure‐226‐11‐17‐2015/s8gr‐6b6i/data

Report CPT 4004F

Report CPT 1036F

Report CPT 4004F‐1P

Report CPT 4004F‐8P

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Matching Data Requirements to Workflow:Measure #226 Example

Required Data How and Where is this data typically captured? Who Captures the data?

Age≥ 18 @ time of visit Typically calculated from DOB in EHR Front office staff

Visit CPT code Chosen by provider @ time of encounter completion/bill generation Provider (possibly coder)

Date of visit Automatically calculated based on date of service Auto generated

Reports current tobacco use? Typically a checkbox or part of social history – varies on EHR Provider/Medical Assistant/Nurse

If tobacco user, was counseling provided?

May be a CPT code, may be a separate checkbox – varies by EHR Provider

If tobacco user, was pharmacotherapyprescribed?

May be a checkbox, may be based on specific Rx given during or after the visit completion – varies by EHR

Provider13

Considerations on Data Capture• What practice‐level incentives are in place to ensure staff and clinicians are capturing the right data, in the right place, and at the right time?

• What and how often are reports reviewing the quality and completeness of the data captured being run? Who reviews these reports? How is feedback offered to correct or praise people in the practice?

• What mechanisms, policies, and/or procedures are in place to amend the medical record if problems of missing or inaccurate data are discovered?

• For your EHR and other data tools, what is the time lag between when data is recorded/entered in the EHR to when scorecards or quality measure reports are updated for review?


Considerations on Reporting Data to CMS…Before allowing your registry vendor (QR, QCDR, or your EHR acting in the role of QR) to submit data, consider the following:

• Have you sent test versions of your data to CMS? (will be available in some software in late 2017)

• Have you confirmed what measures will be reported to CMS?• Have you reviewed the data to be submitted for each clinician and checked it against internal reports?

• Will you have confirmation of transmission to CMS AND a copy of the exact data file(s) sent?

• Are you aware of when and how CMS will report their calculated MIPS score for your practice and/or clinicians?

• Are you aware of the deadlines and steps CMS offers to appeal/amend scoring on submitted quality (and other) data?


Possible Changes for 2018:Updates From the proposed rule released in June 2017

(see https://qpp.cms.gov/about/resource‐library)

• The quality category of MIPS will remain worth 60/100 points of the MIPS composite score for 2018.

• CMS has now proposed a nephrology specific quality measure bundle (See appendix table B.21 in the proposed rule and the next slide)

• CMS has proposed a bonus of up to 10 points for clinicians or groups that show significant year to year improvement between 2018 and 2019 reporting years.

• CMS proposes to accept data from more than one submission method for a single category. This may ease some burden of reporting quality on ESRD patients when data is gathered in multiple EHRs (office and dialysis unit‐based).

• CMS has proposed 1 possible change to scoring – measures with incomplete data may be scored at 1 point as opposed to 3 points (except for small and rural practices).

• CMS has proposed to sunset topped‐out measures over 4 year period starting in 2018.


2018 Proposed Rule:Possible Nephrology‐

Specific Quality Measure Bundle

Table B.21 in the proposed rule

RPA Guide to QPP Participation

For additional resources, including a list of MIPS measures relevant to nephrology, visit www.renalmd.org/physiciandevelopment


Considerations Choosing MIPS Quality Measures · •Quality portion of MIPS composite score = 60...

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