What are the Quality performance category reporting requirements for MIPS?

What is the Quality performance category?
Under the Merit-Based Incentive Payment System (MIPS) pathway of the MACRA Quality Payment Program, the Quality performance category has replaced PQRS. Quality is one of the three performance categories that will be considered and weighted for scoring an eligible clinician’s performance under the Merit-based Incentive Payment System (MIPS). In particular, the Quality performance category will account for 60% of each clinician’s MIPS Final Score (the overall MIPS score) for the 2017 reporting year. Please note that starting in 2018, four performance categories will be considered and weighted for scoring a clinician’s overall performance under MIPS.

What are the MIPS quality measure reporting requirements for 2017?  
Under MIPS, eligible clinicians will be required to report up to 6 quality measures, including at least one outcome measure or high-priority measure, for a minimum of 90 days during the 2017 performance year. Practice Fusion currently supports 23 eCQMs that can be reported for MIPS for the 2017 performance year. The eCQMs that are currently supported by Practice Fusion in 2017 consist of the following:

CMS ID

NQF Number

Measure Title

CMS 2v6

0418

Preventive Care and Screening: Screening for Depression and Follow-Up Plan

CMS 22v5

N/A

Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

CMS 50v5

N/A

Closing the Referral Loop: Receipt of Specialist Report

CMS 68v6

0419

Documentation of Current Medications in the Medical Record

CMS 69v5

0421

Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up

CMS 90v6

N/A

Functional Status Assessment for Congestive Heart Failure

CMS 122v5

0059

Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)

CMS 123v5

0056

Diabetes: Foot Exam

CMS 124v5

0032

Cervical Cancer Screening

CMS 125v5

N/A

Breast Cancer Screening

CMS 127v5

0043

Pneumococcal Vaccination Status for Older Adults

CMS 130v5

0034

Colorectal Cancer Screening

CMS 131v5

0055

Diabetes: Eye Exam

CMS 138v5

0028

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

CMS 139v5

0101

Falls: Screening for Future Fall Risk

CMS 147v6

0041

Preventive Care and Screening: Influenza Immunization

CMS 149v5

N/A

Dementia: Cognitive Assessment

CMS 153v5

0033

Chlamydia Screening for Women

CMS 155v4

0024

Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents

CMS 156v5

0022

Use of High-Risk Medications in the Elderly

CMS 164v5

0068

Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet

CMS 165v5

0018

Controlling High Blood Pressure

CMS 166v6

0052

Use of Imaging Studies for Low Back Pain

Benchmarks & performance points
Quality measures that are reported can contribute 3-10 points towards a clinician’s MIPS Final Score if the measure can be reliably scored against a benchmark. According to CMS, this means:

  1. A benchmark exists for the measure.
  2. The data a clinician is reporting meets the minimum case number requirement (≥ 20 cases for most measures).
  3. A clinician submits at least 50% of the data possible for the measure.

If a quality measure that a clinician submits cannot be reliably scored against a benchmark, he or she will still earn 3 points for that measure if data is reported.

To determine points for each measure, CMS compares an eligible clinician’s performance to published benchmarks  that are based on national performance in a baseline period. Points are assigned based on the decile range in which the clinician’s performance data falls at the end of the performance period. All scored measures receive at least 1 point and partial points are assigned within deciles based on percentile distribution. Eligible clinicians with performance in the top decile (Decile 10) will receive the maximum 10 points available for the measure. Eligible clinicians who do not report the maximum number of measures will receive 0 points for each measure not reported, unless they could not report the maximum number due to insufficient applicable measures.

The relevant benchmarks for each eCQM that the Practice Fusion EHR will support for the 2017 performance year are detailed below.




As an example, a clinician with a measure performance rate of 65% for Controlling High Blood Pressure (CMS 165v5) would fall within the Decile 6 range and receive between 6.0 and 6.9 points for that measure. A clinician with a performance rate of 85% would fall within the Decile 10 range and receive the maximum 10 points available.

Bonus Points
Clinicians may receive bonus points for any of the following:

  • 2 bonus points for each additional outcome and patient experience measure submitted.
  • 1 bonus point for each additional high-priority measure submitted.
  • 1 bonus point for using CEHRT to submit measures to registries or CMS.

How is the Quality performance category scored under MIPS?

The maximum Quality performance category score cannot exceed 100% and for clinicians using the Practice Fusion EHR to report on the Quality performance category, the maximum number of available points will generally be 60 (6 required measures x 10). 

What if I cannot find 6 quality reporting measures relevant to my practice?
If you cannot find 6 quality reporting you wish to report on from those supported by Practice Fusion, you may explore other quality measure reporting mechanisms or report as many measures as you can from Practice Fusion. Under MIPS, you can receive credit for reporting any measure, up to 6, that has data in the denominator and numerator. You may also explore other quality measure reporting mechanisms that may be better for your practice such as claims-based reporting.

More information
You can visit Practice Fusion’s Quality Payment Program resource center here.

Further details of the MIPS program requirements can be found here.

CMS also provides further resources about the Quality Payment Program here.

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