When reporting quality measures, either for the Merit-based Incentive Payment System (MIPS) or other payment or quality improvement programs, many practices often encounter errors related to missing data. In order to successfully report a quality measure, a practice must successfully collect and report data to satisfy all denominator and numerator criteria listed within the measure specification.
Missing data errors can occur during both data collection and data reporting.
If a practice finds that they are missing quality measure data in their reports, the first step is to carefully review the specifications for the affected measures. In particular, a practice should review the individual denominator and numerator criteria for each affected measure to be sure that all required information for the measure is consistently captured and reported. Because most measure denominators rely on the reporting of specific procedure or encounter codes, it is a common error for practices to try to report a quality measure when they do not bill an appropriate encounter or procedure found in the measure denominator. In addition to encounter or procedure codes, some quality measures have additional denominator criteria that require reporting of ICD-10 codes or measure- and registry-specific quality codes. Similarly, reporting of a quality measure numerator typically involves a measure-specific quality code.
To minimize your risk of data errors, you should work closely with your chosen registry, electronic health record and/or other data submission mechanism to regularly review your measure data to ensure you are collecting and reporting accurate codes to report the measure. If you do spot a discrepancy in your reports, make sure you understand where in the capture and reporting process the error occurred and what your practice may need to do to consistently report accurate data in the future.
FAQRAs are created by ASA’s Department of Quality and Regulatory Affairs (QRA). These short articles address informative and relevant topics related to quality in anesthesia practice. For additional questions or information, please contact QRA at (202) 289-2222 or via email firstname.lastname@example.org.