Quality FAQs (2021)

The following questions and responses for the Quality MIPS category are based upon the CMS Final MACRA Rule and the 2021 QPP Final Rule.

1. How many of the total MIPS points is the MIPS Quality Performance Category worth?
The MIPS Quality Performance Category is worth 40 points of the 100 total MIPS points available. If the eligible clinician (EC) or group does not need to report the MIPS Promoting Interoperability category (worth 25 points), the value of the quality category will increase to 65 points. If a cost measure cannot be attributed to the EC or group, then the MIPS Quality performance category will be worth an additional 20 points. Therefore, if PI is not required to be reported and CMS cannot attribute any cost measures to the EC or group, the Quality category will be worth 85 points of the 100 total MIPS points available.

2. How many quality measures must I report?
MIPS ECs and groups must report six (6) measures during the 12-month MIPS reporting year. If fewer than six (6) measures apply to the EC or group, and a QCDR mechanism is not being used, the eligible clinician or group 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, care coordination, or are related to opioids. High priority measure designations are displayed on the Quality Payment Program (QPP) website

ECs and groups using a Qualified Registry or a Qualified Clinical Data Registry must report data for all patients, regardless of payer. At least 70 percent of the MIPS eligible clinician’s or group’s denominator-eligible patients for each measure (Medicare and other payers) must be reported to meet the minimum reporting requirements.

3. What types of quality measures can I report?
For ECs and groups reporting via the Qualified Registry, only MIPS clinical quality measures may be reported. These measures are identified by “MIPS XXX” or "QID XXX". If ECs and groups cannot find six MIPS measures to report, they must report all the measures that apply to their patient population. 

For ECs and groups reporting via the Qualified Clinical Data Registry (QCDR), both MIPS clinical quality measures, those identified by “MIPS XXX” (or "QID XXX"), and QCDR measures may be reported in any combination. ASA/AQI NACOR QCDR measures are identified by the measure number “AQIXX.” AQI NACOR also supports the reporting of two measures that are stewarded by external organizations. ECs and groups reporting via the QCDR must report at least six measures, including an outcome or other high-priority measure.

4. Where can I find MIPS Quality measure specifications?
All MIPS clinical quality measures are available in the Quality Payment Program Resource Library. Measure specifications may have changed from previous years. ECs and groups should make sure they are accurately reporting quality measures for the current performance year.

5. Where can I find MIPS Qualified Clinical Data Registry measure specifications?

Each QCDR owns or displays its own QCDR measure specifications. For AQI QCDR participants, QCDR measure specifications are available on the AQI NACOR website. Measure specifications may have changed from previous years. ECs and groups should make sure they are accurately reporting quality measures for the current performance year.

6. How are quality measures scored?
Eligible clinicians will receive credit for the quality measures they successfully report. Each measure will be scored on a 0 to 10-point scale based upon an eligible clinician or group practice’s performance. In some cases, for groups of 16 or more eligible clinicians, CMS will apply population-based measures. A total of 60, 70, or 80 points, depending on practice size can be gathered by this process.

For 2021, CMS may assess groups on two claims-based reporting measures. Those measrues are “Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment Program” and the “Risk-standardized complication rate (RSCR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) for Merit-based Incentive Payment System.” 

Measure-specific benchmarks, based upon a measure's performance rate, are established by the Centers for Medicare & Medicaid Services (CMS) to determine an eligible clinician's score on the 10-point scale. CMS will award points to eligible clinicians based on benchmarking performance rates. Each benchmark must have a minimum of twenty (20) MIPS eligible clinicians who reported the measure for at least twenty (20) cases. Each measure must have a data completeness of more than 70% of the cases to which the measure applies. Benchmarks are updated based on performance in the previous year. Same year benchmarking is available if historical benchmarks are not available and ifthe minimum criteria described above are met. 

Also note that CMS encourages the reporting of outcome measures, high-priority measures and measures reported electronically more than process measures. In addition to reporting these measures, practices should also submit more than six measures when available to maximize their bonus points.

Please visit the ASA Quality performance category scoring webpage for more details. 

7. How is the MIPS Quality Category scored?
To score an individual measure, first find the decile that your performance rate for the year applies. You will then subtract the bottom of the decile range from your performance rate. That figure will then be divided by the sum of the top of the decile range minus the bottom of the decile range. The divided number is added to the decile to which your performance rate fits and multiplied by 0.9. This will give you a figure for that specific measure to one decimal point. CMS provides this algorithm on the Quality Payment Program Resource Library.

If reporting via a qualified registry and you have reported on less than six measures but all the measures that apply to your patient population, CMS will proportionally increase the 10-point scale. For instance, if you reported on three measures and no other measures applied to you or your group, those measures will be scored out of 20 points. The method of evaluating whether all measures applicable to the practice were reported is known as the “Eligible Measures Applicability (EMA)” process.

When each measure is scored, those scores, along with CMS assessment of the one population-based measure that is dependent on group practice size, will be summed and then divided by 60, 70, or 80 points possible in the MIPS Quality performance category. That score would then be multiplied by 40 points possible to determine the Quality performance category score of the MIPS total performance score.