1. MIPS Reporting - Quality
2019 Reporting Guide for CRNAs
The AANA Research and Quality department prepared this is a brief overview of MIPS Quality performance category in 2019, as it applies to CRNAs who are eligible to participate in MIPS. This is Year 3 of the MIPS program.

2. MIPS Reporting Categories
Quality
Improvement Activities (IA)
Promoting Interoperability (PI)
Cost
*Most CRNAs will report data for the Quality and IA categories.
Quality is one of the four performance categories MIPS Eligible Clinicians (EC) can report. The Quality and Improvement Activities most often pertain to CRNAs, based on the services they provide.
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3. Quality Performance Category
Measures health care processes, outcomes and patient experiences
Reported by individual clinicians and groups
Consists of data collected for an entire calendar year (January 1st to December 31st), called the performance period.
CRNAs report measure data that reflect healthcare care processes, outcomes and patient experiences. CMS also refers to the12-month performance period as the performance year.
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4. Quality Performance Category (cont).
45% final Score
(for CRNAs reporting PI* with applicable Cost Measures)
70% final Score
(for CRNAs NOT reporting PI*, but with applicable Cost Measures)
85% of final score
(for CRNAs NOT reporting PI* with NO applicable Cost Measures)
*PI – Promoting Interoperability
This illustrates the weights of each performance category in relation to the MIPS Final Score, which is calculated as percentage. The categories can be re-weighted based on applicability of the Promoting Interoperability and Cost Measures. The first chart shows the weight of the Quality category at 45%, when a provider reports all four MIPS categories; 70% when reporting three categories (no PI); and 85% when reporting Quality and IA only. No PI or Cost measures.
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5. MIPS 2019 Full Participation Requirements
Performance Category
QUALITY-- 45%
What you need to do
For all CRNAs: Report on at least 6 applicable measures including 1 outcome or high priority measure for at least 60% of ALL your patients for FULL calendar year
Category weight = 45%
Reweight = 70% (not reporting PI)
Reweight = 85% (no PI/Cost)
Subject to Reweight
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6. MIPS 2019 Full Participation (cont.)
Full participation in the Quality Performance category requires:
Reporting at least 6 applicable measures
One measure should be an outcome or high-priority measure*
Report on at least 60% of all patients for the full calendar year, and meet measure volume requirements (at least 20 cases) for data completeness
*A high-priority measure is defined as outcome, appropriate use, patient safety, efficiency, patient experience and care coordination. For 2019, opioid-related measures were added to the definition.
The minimum volume to report measures is 20 cases. CRNAs must report at least 60% of Medicare Part B patients for the year. A high-priority measure evaluates outcome, appropriate use, patient safety, efficiency, patient experience and care coordination. For 2019, opioid-related measures were added to the definition.
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7. Quality Measure Benchmark
CMS awards between 3 and 10 points for each measure in the Quality performance category.
The points awarded are based on a benchmark calculated from previous data. Benchmark data is available on the CMS Quality Payment Program website.
New measures that do not have a benchmark, will be awarded only 3 points.
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8. Quality Data Collection and Reporting
Individual and Group Reporting
Additional Reporting
Options
Data Collection Types
QCDRs
Qualified Registries (QRs)
Electronic Health Record/EHR
MIPS Clinical Quality Measures (formerly Registry measures. Collected by QCDRs and QRs)
Additional Data Collection Types
Web interface (large groups of 25 or more clinicians)
Alternative Payment Model (APMS) qualifying for special MIPS scoring
Medicare Part B claims (small groups)
CRNAs in solo or group practices have these options for reporting MIPS data to CMS: Qualified Clinical Data Registries (QCDRs), Qualified Registries (not evaluated by CMS, but can submit data), direct submission of MIPS data from a certified EHR or Health IT system; MIPS CQMs. Group practices have additional options, including CMS Web Interface for larger groups and measure data from Medicare Part B claims. Some APMS also qualify for special MIPS scoring.
It is important to note that individual CRNAs can submit the same quality measures using more than one reporting type. The measure with the highest number of achievement points will be selected for performance category scoring.
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9. Qualified Clinical Data Registry (QCDR)
Reporting May Be a Better Option for MIPS
Claims/EHR/Registry
QCDRs
CRNAs are limited to MIPS measures for meeting the Quality Category requirements
AND
CRNAs will have to find appropriate activities to fulfill the Improvement Activities Category
Allows CRNAs to fulfill the Quality Category requirements with anesthesia QCDR measures
AND
Provides opportunities for completing and attesting to several Improvement Activities
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10. Data Completeness and Bonus Points
The small practice bonus is 6 points for MIPS-eligible clinicians who submit data for at least one quality measure. The bonus will be added to the Quality performance category score in 2019.
Small practices can receive up to 3 points for reporting quality measures that do not meet data completeness requirements (reporting on least 60% of all patients).
Two bonus points can be awarded for reporting outcome and patient experience measures.
One point can be awarded for other high-priority measures that meet data completeness and case minimum requirements.
The bonus for small practices remains at 6 points from Year 2 (2018), but they will be added to the Quality performance category numerator. Small practices can receive up to 3 points for reporting quality measures that do not meet data completeness requirements.
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11. Quality Performance Category (cont.)
The Performance Threshold for 2019 is 30 points in order to avoid the 7% penalty.
Bonus points for exceptional performance can be earned for achieving 75 points.
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12. 2019 Anesthesia MIPS Quality Measures (cont.)
ID#
Measure Title
Measure Type
High Priority 44
Coronary Artery Bypass Graft (CABG): Preoperative Beta-locker in Patients with Isolated CABG Surgery
Process No 76
Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections
Yes
404
Anesthesiology Smoking Abstinence
Intermediate
Outcome
424
Perioperative Temperature Management
430
Prevention of Post-Operative Nausea and Vomiting (PONV)-Combination Therapy—Adults
463*
Prevention of Post-Operative Vomiting (POV)-Combination Therapy—Pediatrics
*MIPS #463 is new for 2019.
The 2019 Anesthesia MIPS measures, have changed where #463 was added; MIPS #426 and MIPS #427 were removed because CMS determined them to be topped out. These measures are categorized by type of measure and priority status.
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13. Additional Resources QPP website: https://qpp.cms.gov
QPP Participation Status Tool:
QPP Resource Library:
Phone: (Monday through Friday)
Determination periods for the 2019 reporting year:
First: October 1, September 30, 2018
Second: October 1, September 30, 2019
Additional information about reporting requirements, scoring and data submission requirements 2019 can be found here. CMS offers resources in print, video and webinars. Use your National Provider Identification (NPI) number to use the Participation Status tool, which contains data from two determination periods that indicate eligibility for reporting MIPS.
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