Quality Measure Reporting Mechanisms
There are several reporting mechanisms available for submitting MIPS quality measure data. Many of these can also be used to submit data for the Promoting Interoperability and Improvement Activities categories of MIPS. There is no reporting requirement for the Cost performance category of MIPS as CMS will use claims data to determine scores in this category.
In 2018 practices must submit all quality data through the same reporting mechanism. However, this may change in 2019.
Claims Reporting Mechanism
This mechanism is available to clinicians reporting as individuals only. It is not available to practices reporting as a group. Clinicians that elect to report using this mechanism need to attach applicable quality-data codes to claims forms submitted to CMS for Medicare beneficiaries only. The quality-data code needs to be submitted along with the claim for denominator eligible encounters/events when it is first reported. The code added to the claim needs to show whether the measure’s performance was or was not met or if there was an exception or exclusion.
Quality data-codes cannot be submitted retrospectively via this mechanism. They must also be reattached each time the claims is submitted (e.g., when a claims is resubmitted secondary to a denial or other reason).
For 2018 practices reporting via claims need to submit data on 60% of applicable Medicare encounters or procedures for the entire 2018 calendar year.
For the 2018 performance period, claims should be submitted to the practice’s regional Medicare Administrative Contractor (MAC), including claims adjustments, re-openings, or appeals by March 2, 2019. Clinicians should check with their MAC to see if there are specific reporting instructions for submitting quality data via claim forms.
Qualified registries that can report MIPS data are organizations that have been approved by CMS to submit quality performance and other types of MIPS data to CMS. They assist with the collection of data and with ensuring that the data is accurate for reporting to CMS.
There are 140 approved registries to choose from: 2018 Qualified Registry List
Qualified Clinical Data Registries
Qualified Clinical Data Registries that have been approved by CMS may also report MIPS data to CMS. Many QCDRs are also approved quality measure development organizations. Some quality measures are specific to QCDRs and tend to be oriented to specific specialties of medicine. Approved measures may also be submitted as MIPS quality measures and may be used to determine the MIPS performance score.
There are 140 QDRS approved for reporting to CMS in 2018: 2018 QCDR List
Electronic Health Record (EHR)
Clinicians submit data collected through their certified EHR technology (CEHRT) directly to CMS. Clinicians can do this themselves, if supported by their EHR, or by working with a qualified health IT vendor who can submit their data for them.
Groups (as defined by a single TIN) and Virtual Groups that capture data using multiple EHR systems will need to aggregate their data before it’s submitted to CMS. This is also true for practices participating in MIPS APMs.
CMS Web Interface
This mechanism is only available to groups of 25 or more clinicians and for Medicare Shared Savings Program Accountable Care Organizations (MSSP ACO’s) reporting on behalf of MIPS eligible clinicians. Groups of 25 or more clinicians reporting as virtual groups may also report via this mechanism.
It is a secure web-based application that requires preregistration between April 1st and June 30th of the performance year. CMS will identify a sample of beneficiaries are identified that are used for reporting. They will then partially pre-populate the CMS Web Interface with claims data from the group’s Medicare Part A and Part B beneficiaries who’ve been assigned to clinicians in the group. The group will then add the clinical data for use in determining performance on the quality measures.
All quality measures must be submitted. If there is insufficient sample size (i.e., 248 or more patients) CMS will provide alternative reporting options.
Consumer Assessment of Healthcare Providers & Systems (CAHPS) for MIPS Survey Vendors
CAHPS is an optional quality measure that groups may elect to report as one of their quality performance measures. This reporting mechanism is not available to clinicians reporting individually.
CAHPS measures ten key domains of beneficiaries’ experiences of care. The CAHPS for MIPS survey may only be administered by CMS-approved vendors.
Groups and Virtual Groups that plan to administer the CAHPS for MIPS survey need to register via qpp.cms.gov between April 1, 2018 and June 30, of the performance year. Groups that choose to report their patient experience data via the CAHPS for MIPS survey have to choose another data submission mechanism to submit their remaining quality measures.
Groups must meet minimum sample sizes to administer the CAHPS for MIPS survey. CSM will let groups know if they meet minimum sample sizes once group registration closes and assignment sampling finishes. The CAHPS for MIPS survey is oriented towards primary care providers and is not applicable to specialists that do not provide primary care services.
Clinicians are responsible for the costs that go with survey administration.