Quality Measure Reporting Frequencies – Definitions

Reporting frequency definitions are provided for each measure and included in each measure’s specification document.  As per CMS “…The analytical submitting frequency defines the time period or event in which the measure should be submitted…”  Individual clinicians and groups should report data depending on which frequency definition has been defined for the measure.

The following definitions are applicable in 2018:

• 1. Patient-Intermediate measures are submitted a minimum of once per patient during the performance period. The most recent quality-data code will be used if the measure is submitted more than once.
     • This can influence performance on the measure significantly for outcome measures in particular.  For example, a patient has an HbA1C value of 9.5% in September.  If the patient is seen again before the end of the year (and the encounter is clinically appropriate) and the HbA1c fall to 8.5% the measure will be reported as “performance met.”  However, if the patient is again seen and tested in January of the following year the performance will be treated as performance not met, even if multiple prior HbA1c levels earlier in the year were below 9.0%.
  2. Patient-Process measures are submitted a minimum of once per patient during the performance period. The most advantageous quality-data code will be used if the measure is submitted more than once.
     • This type of measure only required the measure to be reported once for each patient during the performance period, even if multiple encounters meet the denominator requirement.  There is no value in reporting this measure on a single patient more than once during the performance period one performance on the measure has been met.
  3. Patient-Periodic measures are submitted a minimum of once per patient per timeframe specified by the measure during the performance period. The most advantageous quality-data code will be used if the measure is submitted more than once. If more than one quality-data code is submitted during the episode time period, performance rates shall be calculated by the most advantageous quality-data code.
     • This does require the measure to be submitted for each patient at least once during a designated time period (e.g., 3 months).  An example of this is the Influenza Vaccine measure that has two reporting periods during the year; January to March and October to December.  If the patient is seen during each reporting period this measure needs to be submitted at least once for each reporting period.  However, if multiple encounters are reported for each reporting period, CMS will use the result in the most advantageous to the clinician/group.
  4. Episode measures are submitted once for each occurrence of a particular illness or condition during the performance period.
     • This means that performance on this measure is episode dependent and could be reported multiple times during the year on the same patient.   All submitted codes will be used to determine performance on this measure.
  5. Procedure measures are submitted each time a procedure is performed during the performance period.
     • Like the Episode measure above, all submitted codes for each performed procedure during the reporting period are used to determine performance.
  6. Visit measures are submitted each time a patient is seen by the individual eligible clinician during the performance period.
     • For this measure each visit for the same patient is treated as “unique” and will be used to determine overall performance.

  Source: 2018 Quality Payment Program (QPP) Measure Specification and Measure Flow Guide for Registry Submission of Individual Measures (document dated 6/22/2018) and CMS Quality Support – Production (Date 6/7/2018)

Notables: For the patient-intermediate measure the most recent quality-data code reported will be used to assess performance on the measure.  For the patient-process and patient periodic measures CMS will use the most beneficial performance on the measure if it is submitted more than once. Knowing the reporting frequency definitions for the measures you are reporting could encourage practices to ensure that all medically necessary visits and tests have been performed during the entire reporting period (e.g., HgA1c in diabetic patients).