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 should report at least 6 quality measures, including at least one outcome measure or high-priority measure, for a minimum of 90 days during the 2017 performance year. However, eligible clinicians can earn points in the Quality performance category for any number of measures that are submitted. 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:


NQF Number

Measure Title

CMS 2v6


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

CMS 22v5


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

CMS 50v5


Closing the Referral Loop: Receipt of Specialist Report

CMS 68v6


Documentation of Current Medications in the Medical Record

CMS 69v5


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

CMS 90v6


Functional Status Assessment for Congestive Heart Failure

CMS 122v5


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

CMS 123v5


Diabetes: Foot Exam

CMS 124v5


Cervical Cancer Screening

CMS 125v5


Breast Cancer Screening

CMS 127v5


Pneumococcal Vaccination Status for Older Adults

CMS 130v5


Colorectal Cancer Screening

CMS 131v5


Diabetes: Eye Exam

CMS 138v5


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

CMS 139v5


Falls: Screening for Future Fall Risk

CMS 147v6


Preventive Care and Screening: Influenza Immunization

CMS 149v5


Dementia: Cognitive Assessment

CMS 153v5


Chlamydia Screening for Women

CMS 155v4


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

CMS 156v5


Use of High-Risk Medications in the Elderly

CMS 164v5


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

CMS 165v5


Controlling High Blood Pressure

CMS 166v6


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 measures 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.

For more information on the Practice Fusion QCDR and MIPS estimated scoring, click here.

Quality Payment Program

  1. Quality Payment Program: What is the Merit-Based Incentive Payment System (MIPS)
  2. How do I report my 2017 MIPS data to CMS using the Practice Fusion QCDR?
  3. What is the Advancing Care Information (ACI) Performance Category for MIPS and how is it scored?
  4. 2017 ACI Transition Measure: Security Risk Analysis
  5. 2017 ACI Transition Measure: Electronic Prescribing (eRx)
  6. 2017 ACI Transition Measure: Provide Patient Access
  7. 2017 ACI Transition Measure: Health Information Exchange
  8. 2017 ACI Transition Measure: View, Download, or Transmit (VDT)
  9. 2017 ACI Transition Measure: Patient-Specific Education
  10. 2017 ACI Transition Measure: Secure Messaging
  11. 2017 ACI Transition Measure: Medication Reconciliation
  12. 2017 ACI Transition Measure: Immunization Registry Reporting
  13. 2017 ACI Bonus Measure: Syndromic Surveillance Reporting
  14. 2017 ACI Bonus Measure: Specialized Registry Reporting
  15. What is the Improvement Activities Performance Category for MIPS?
  16. What are the Quality performance category reporting requirements for MIPS?
  17. What is the difference between the two Advancing Care Information measure sets available in 2017?
  18. Advanced APM: What is Comprehensive Primary Care Plus (CPC+)?
  19. Which Improvement Activities Qualify for the Advancing Care Information (ACI) Bonus Score in 2017?
  20. What is the MIPS Dashboard watch list and how do I use it?
  21. How does the MIPS Dashboard work?
  22. How is the MIPS Final Score Calculated?
  23. MIPS for Small, Rural and Underserved Practices
  24. How do I contact CMS about the Quality Payment Program?
  25. What is the Practice Fusion QCDR?
  26. How do I indicate interest in the Practice Fusion QCDR and get my MIPS estimated scores?
  27. Chronic Care Management FAQs
  28. 2018 ACI Transition Measure: Health Information Exchange
  29. How do I export a JSON file for 2017 MIPS reporting?

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