MIPS: Quality Scoring

 

Questions for each measure within the Quality wizard (Progress Note > MACRA > Quality) are divided into Denominator questions and Numerator questions. 

 

Only if a measure satisfies the Denominator criteria (based on the answers) will it be reported in the Quality report. Each measure has several conditions for meeting the Denominator criteria. In our system, for some measures, these criteria are automatically satisfied (e.g. measure 47), but for some measures, the user needs to answer questions. If the answers follow the Denominator requirements, the visit will be reported (e.g. measure 410).

 

Let's look at an example with measure 410. In order to get a visit in the Denominator, the patient has to have Psoriasis Vulgaris (or other Dx that satisfies the Denominator criteria), has to have one of the E&M codes (we always predefine this type of question with YES, as the purpose of this question is to prove that you had a face-to-face encounter), and to be treated with systemic or biologic medication for at least six months. Only if you report Yes on all three questions will the measure be eligible, as you satisfied the Denominator criteria. If the patient has Psoriasis Vulgaris and thus 410 is available on the encounter, but you reported No on the biologics question, that visit won't have an influence on your Performance Rate and Reporting Rate. Each denominator question in the Quality wizard is marked as "Denominator Criteria" in the question's description.

 

Performance Rate is the most important value since your MIPS score for Quality directly depends on it. Performance Rate = all visits that met the criteria / (patients that have completed visits - patients that were excluded)

 

For easier comprehension of this formula, you need to know that a visit that passed the Denominator criteria could be categorized as "Met," "Not Met," "Incomplete," or "Exclusion" (exclusion is not available for all measures). Each measure can be reported only as one of these (M/NM/E/I), and whether it is met/not met/exclusion/incomplete depends on your answers. The visit is incomplete if you have not finished a wizard in the Numerator part (e.g. you left the last question unanswered).

 

The ultimate goal of the eligible clinician is to have as many visits that MET the criteria as possible, and as few visits that did not meet the criteria as possible, since these directly increase and decrease Performance Rate. Based on your Performance Rate and the benchmark CMS provided for that measure, you'll earn from 3 to 10 points each. 

 

An example: Let's say you have 80 patients that satisfied the Denominator criteria for #265. From these 80 patients, 40 patients MET the criteria, 10 reported as exclusion, 10 are incomplete and 20 patients were reported as NOT MET. Your performance rate will be calculated as 40/(70-10) = 0.6667. Since this rate is measured in percentage, your rate is 66.67%. Now, for #265 with this performance rate, you'll be in Decile 4 (based on CMS benchmark), so it means that you'll earn between 4 and 5 points. Benchmark for each measure is different and some measures don't have it. Those will give you 3 points at all, no matter what is your Performance Rate (e.g. 410 and 440). This is just for now, as CMS could provide a benchmark later on. As a side note: If you report less than 20 visits for some measure, you'll also earn 3 points out of 10 if you have at least one measure as MET.

 

Reporting Rate has to be above 70% (CMS requirement). If satisfied, the value of this rate is not important for the final score, as it just has to be greater than 70% as a proof that you reported for at least 70% of eligible patients. If you have it at 71% or 100%, it would be counted the same. Reporting Rate = (MET + NOT MET + Exclusions) / visits that passed the Denominator part. In the example given above for #265, your Reporting Rate would be (40+20+10)/80=0.875, and this rate is also measured in percentage, so it would be captured at 87.50%.