MIPS Quality Component

MIPS Quality Component

CMS finalized the MIPS Quality component to account for 60% of an eligible clinician's composite score in performance year 2017 (payment year 2019). The MIPS Quality component replaced the Physician Quality Reporting System (PQRS) for reporting purposes on January 1, 2017.

Anesthesiologists may elect to submit quality measures through any of the following mechanisms. Reporting specific measures is dependent upon the mechanism an eligible clinician or group practice chooses to report.

Except for Web Interface and CAHPS for MIPS, physician anesthesiologists may use these reporting mechanisms to report quality measures either individually or as a group via the Group Practice Reporting Option. Under MIPS, group practices of more than 100 eligible clinicians are no longer required to report a CAHPS survey. For the Quality component, eligible clinicians must report six (6) quality measures, including one (1) outcome measure. Reporting CAHPS for MIPS will count as one (1) of the six (6) required measures in the Quality component category and groups reporting this measure would receive bonus points in reporting year 2017. Practices must use another reporting mechanism to submit its remaining five (5) measures.

MIPS Quality Measures

MIPS eligible clinicians must report six (6) measures during the 12-month MIPS reporting year. If fewer than six (6) measures apply to the eligible clinician, the eligible clinician must report on all applicable measures. One (1) of the six (6) measures must be an outcome measure. If there is no applicable outcome measure, the eligible clinician must report a high priority measure instead. High priority measures are defined as those that measure appropriate use, patient safety, efficiency, patient experience or care coordination. Eligible clinicians are no longer required to report across multiple National Quality Strategy (NQS) domains. 

Reporting a cross-cutting measure is NOT required under MIPS.

MIPS eligible clinicians may select their measures from a list of all MIPS measures or from a set of specialty-specific measures. Measure specifications for performance year 2017 are available on the CMS Quality Payment Program website. Remember that measure specifications may have changed from previous years. Practices should make sure they are accurately reporting quality measures for the current performance year.

CMS finalized the Anesthesiology Specialty-Specific Measure Set for physician anesthesiologists for performance year 2017:

  • MIPS #44: CABG: Preoperative Beta-Blocker in Patients with Isolated CABG Surgery 
  • MIPS #76: Prevention of CVC-Related Bloodstream Infections*
  • MIPS #130: Documentation of Current Medications in the Medical Record
  • MIPS #317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
  • MIPS #404: Anesthesiology Smoking Abstinence*
  • MIPS #424: Perioperative Temperature Management*
  • MIPS #426: Post-Anesthetic Transfer of Care Measure: Procedure Room to PACU*
  • MIPS #427: Post-Anesthetic Transfer of Care Measure: Procedure Room to ICU*
  • MIPS #430: Prevention of PONV - Combination Therapy*

* designates a proposed "high priority measure"

MIPS eligible clinicians reporting via QCDR have the option of reporting both QCDR measures and MIPS measures. Additional information on the available measures for reporting via QCDR is available on the AQI website.

MIPS Quality Reporting Criteria

For the 2017 MIPS Quality Component, MIPS eligible clinicians must report at least six (6) measures for a minimum of 90 days. If fewer than six (6) measures apply to the eligible clinician, the eligible clinician must report on all applicable measures.

Anesthesiologists may elect to submit quality measures through any of the following mechanisms. Reporting specific measures is dependent upon the mechanism an eligible clinician or group practice chooses to report. 

Claims, Individual Reporting Only: Report at least six measures and at least one outcome measure, or if an outcome measure is not available report another high priority measure; if less than six measures apply then report on each measure that is applicable.MIPS eligible clinicians and groups will have to select their measures from either the list of all MIPS Measures or a set of specialty specific measures. Report 50 percent of MIPS eligible clinician’s Medicare Part B patients. The only anesthesia measure reportable via claims in 2017 is MIPS 76: Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections.

Qualified Registry, Qualified Clinical Data Registry (QCDR) or Electronic Health Record - Individual or Group Practice Reporting Option:  Report at least six measures and at least one outcome measure, or if an outcome measure is not available report another high priority measure; if fewer than six measures apply then report on each measure that is applicable. MIPS eligible clinicians and groups will have to select their measures from either the list of all MIPS measures or a set of specialty specific measures. QCDR participants may also choose from a list of approved QCDR measures. Report at least50 percent of the MIPS eligible clinician’s or group’s denominator-eligible patients for each measure (Medicare and other payers) to meet the minimum reporting requirements.

Web Interface - Group Practice Reporting Option OnlyReport on all measures included in the CMS Web Interface; AND populate data fields for the first 248 consecutively ranked and assigned Medicare beneficiaries in the order in which they appear in the group’s sample for each module/measure. If the pool of eligible assigned beneficiaries is less than 248, then the group would report on 100 percent of assigned beneficiaries.

CAHPS for MIPS Survey - Group Practice Reporting Option Only: Groups are not required to report the CAHPS for MIPS Survey in 2017. If a group chooses to report CAHPS for MIPS, the survey will only count for one measure. Groups must submit through a CMS-approved survey vendor and use another submission mechanism to complete quality data submission for at least five (5) other measures. For groups without an outcome measure, the CAHPS for MIPS Survey fulfills the high-priority measure requirement.

MIPS Quality Scoring

The MIPS Quality component will account for 60 percent of an eligible clinician's composite score in performance year 2017 (payment year 2019).

Eligible clinicians may receive up to 10 points for each measure they successfully submit. If the eligible clinician submits any data with the correct denominator and numerator codes for the measure, the eligible clinician will receive at least three (3) points (measure floor) for that measure in 2017. If an eligible clinician fails to submit any measure data as required under the quality performance category criteria, the eligible clinician will receive zero (0) points for that measure.

Benchmarking: Measure-specific benchmarks, based upon a measure's performance rate, will be established by CMS to determine an eligible professional's score on the 10-point scale. CMS proposes to award points to eligible clinicians based on benchmarking performance rates. CMS provided the following example in the proposed rule (Table 16, Federal Register p. 77281). Each benchmark must have a minimum of 20 MIPS eligible clinicians who reported the measure for at least 20 cases.

TABLE 16: Example of Using Benchmarks for a Single Measure to Assign Points With a Floor of 3 Points

Benchmark Decile Sample Quality Measure Benchmarks Possible Points with 3-Point Floor Possible Points Without 3-Point Floor
Benchmark Decile 1 0.0-9.5% 3.0 1.0-1.9
Benchmark Decile 2 9.6-15.7% 3.0 2.0-2.9
Benchmark Decile 3 15.8-22.9% 3.0-3.9 3.0-3.9
Benchmark Decile 4 23.0-35.9% 4.0-4.9 4.0-4.9
Benchmark Decile 5 36.0-40.9% 5.0-5.9 5.0-5.9
Benchmark Decile 6 41.0-61.9% 6.0-6.9 6.0-6.9
Benchmark Decile 7 62.0-68.9% 7.0-7.9 7.0-7.9
Benchmark Decile 8 69.0-78.9% 8.0-8.9 8.0-8.9
Benchmark Decile 9 79.0-84.9% 9.0-9.9 9.0-9.9
Benchmark Decile 10 85.0%-100% 10 10

Population-Based Measures: Under MIPS, quality performance scores will include the All-cause Hospital Readmission Measure for groups of 16 or more eligible clinicians, with a minimum of 200 cases. Eligible clinicians would not need to submit this measure. Instead, CMS would calculate the measures internally. If a group does not meet the 200 case minimum, the measure will not be scored. The all-cause readmission measure would not be applicable to practices with 15 or fewer eligible clinicians. ASA opposed the inclusion of this measures in the calculation of the Quality component score.

Bonus PointsCMS will award bonus points for reporting measures additional high-priority and outcome measures above initial reporting requirements. Bonus points are capped at 10 percent of total possible points in the MIPS Quality Component.

​Calculation​: The quality performance category score is proposed to be the sum of all the points assigned for the scored measures and any bonus points divided by the sum of total possible points (60 points for practices of 15 or fewer eligible clinicians, 70 points for practices with 16 or more eligible clinicians).

More MIPS Components

You can also find CMS Resources here and ASA FAQs here for all things MACRA.