1. Considerations for Choosing MIPS Quality Measures
January 2018

2. RPA Guide to QPP Participation
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

3. RPA Guide to QPP Participation
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
Only use data that you have access to – data in separate fields that your electronic health record system can export for reports or use to calculate measure performance
RPA Guide to QPP Participation

4. 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
Participant
Submission Method
Measure requirements
Data Completeness
Scoring
Individual
Part B Claims
6 measures or measure set
60% of Part B Patients for 12 months
1-10 points*
Individual or Group
QCDR, Qualified Registry, or EHR
60% of ALL patients who meet denominator inclusion criteria for 12 months
*Small practices will still have 3 point floor
Picture from
Keep 3-point floor for measures scored against a benchmark.
Keep 3 points for measures that don’t have a benchmark or don’t meet case minimum requirement. 
Measures that do not meet data completeness requirements will get 1 point instead of 3 points, except that small practices will continue to get 3 points.
No change to bonuses. 
Starting with the 2018 MIPS performance year, CMS proposes to use a cap of 7 points for a select set of 6 topped out measures:
Topped out measures: For 2018, there are 6 topped out measures that be will scored with a maximum of 7-points instead of the standard 10-points:
#21. Perioperative Care: Selection of Prophylactic Antibiotic-First or Second Generation Cephalosporin
#23. Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)
#52. Chronic Obstructive Pulmonary Disease (COPD): Inhaled Bronchodilator Therapy
#224. Melanoma: Overutilization of Imaging Studies in Melanoma
#262. Image Confirmation of Successful Excision of Image Localized Breast Lesion
#359. Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computerized Tomography (CT) Imaging Description
All tables adapted from

5. Scores for MACRA/QPP – MIPS Quality Category
Quality portion of MIPS composite score = 50 (out of 100) points for 2018
Your MIPS Quality score is based how well you perform on 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 50 points of the MIPS composite score (MCS) is the % of points out of 60 (or 70 for groups >16) quality category points earned.
RPA Guide to QPP Participation

6. MIPS – Quality Measure Score Card Example
# of Cases
Performance Points
High Piriorty?
Topped Out?
CEHRT Use?
Adjustment?
Measure Score #1 20
4.1 N 1
5.1 #2 21
9.3
N/A Y
-2.3 8 #3 22 10 11 #4 50 #5 43
8.5
9.5 #6
9.7
-6.7 3
All-Cause Readmission
205 5
Total Measure Score Points
51.6
Total Measure Score Points
51.6
Max Possible Quality Category Points 70
Quality Category Performance %
74%
MIPS Composite Score - Quality Max 50
Points Earned Toward the Quality Category of MIPS Composite Score 37
Group ≥16 clinicians, therefore 70 maximum possible quality category points (All Cause Readmission measure calculated and applied by CMS)
Used a CMS identified score-capped topped-out measure for #2, therefore 7 is maximal score(-2.3, but +1 bonus point for CEHRT use)
Did not meet the minimum reported cases (20) for measure #6, there for score reduced to 3 (-6.7)
Earned bonus points for reporting via CEHRT and choosing high priority measures (#1,2,3, and 5)
Earned 69% of total possible quality points; 37/50 towards MCS score
Example updated from MACRA final rule TABLE 19: Quality Performance Category Example with High Priority and CEHRT Bonus Points

7. Further 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 EHR submission has the lowest percentage of topped out measures
Measures are scoring has become more complex in 2018
2018 Measure Scoring Adjustments of Note
3-point floor for measures scored against a benchmark (i.e. those CMS publishes)
3-point floor for measures that don’t have a benchmark (new QCDR custom measures)
3-point floor for measures that don’t meet case minimum requirement (<20 cases). 
1-point floor for measures that do not meet data completeness requirements (60% of Part B patients who meet denominator - except that small practices will continue to get 3 points.
6-point ceiling for *some* topped out measures (list published by CMS)
All tables adapted from

8. RPA Guide to QPP Participation
Notes on Registries
Qualified Registries (QRs) are approved vendors that aggregate and report quality data on behalf of subscribing clinicians and practices. MIPS wizard 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
RPA Guide to QPP Participation

9. Notes about ESRD patients
There is a lot of confusion about the ”requirements” for reporting across MIPS categories on ESRD patients.
At a minimum (and depending on how a clinician or group reports data), CMS requires reporting on 60% 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.
RPA Guide to QPP Participation

10. RPA Guide to QPP Participation
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?
RPA Guide to QPP Participation

11. Denominator Inclusion
Example – Smoking Cessation – CMS #226 Preventative Care and Screening: Tobacco Use
Measure: 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 use
and
• circumstances document (terminal illness, etc.) 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
• received counseling (3 min or less), pharmacotherapy, or both
No Screening and/or no intervention without documentation(measure not met)
RPA Guide to QPP Participation

12. Measure #226 Data Workflow and CPTs to be reported
These are CPT II codes
For reporting quality measures
Measure #226 Data Workflow and CPTs to be reported
Report CPT 4004F
Report CPT 1036F
Report CPT 4004F-1P
From
Report CPT 4004F-8P
From

13. Matching Data Requirements to Workflow: Measure #226 Example
Required Data
How and Where is this data typically captured?
Who Captures the data?
Age≥ time of visit
Typically calculated from DOB in EHR
Front office staff
Visit CPT code
Chosen by 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 pharmacotherapy prescribed?
May be a checkbox, may be based on specific Rx given during or after the visit completion – varies by EHR

14. 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 acknowledge data capture behavior?
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?
RPA Guide to QPP Participation

15. 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 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?
RPA Guide to QPP Participation

16. RPA Guide to QPP Participation
Updates for 2018: (see
CMS now has a nephrology-specific quality measure bundle
(See appendix table B.21 in the proposed rule and the next slide)
CMS now offers a bonus of up to 10 % in the quality category (5 MCS points) for clinicians or groups that show significant year to year improvement between 2017 and 2018 performance.
CMS may accept data from more than one submission method for a single category beginning in This may ease some burden of reporting quality on ESRD patients when data is gathered in multiple EHRs (office and dialysis unit-based).
Please see CMS website for more information
RPA Guide to QPP Participation

17. RPA Guide to QPP Participation
2018 Nephrology-Specific Quality Measure Bundle Table B.21 in the proposed rule
RPA Guide to QPP Participation

18. RPA Guide to QPP Participation
For additional resources, including a list of MIPS measures relevant to nephrology, visit
RPA Guide to QPP Participation