2018 MIPS

Quality Performance Category Frequently Asked Questions (FAQs) 

What is the Quality Performance Category in MIPS?

The Quality performance category within MIPS assesses health processes and outcomes through quality measures and is one of four performance categories upon which Eligible Clinicians (ECs) will be judged to determine future Medicare Part B payments by earning points for completion of measures. The Quality Category was designed by CMS to replace The Physician Quality Reporting System (PQRS). Unlike PQRS, the MIPS Quality category is not a “pay-for-reporting” program and does not have a “satisfactory reporting requirement” to avoid  the penalty.

Each quality measure is converted into a 10 point scoring system which enables the CMS to derive a quality score.  A MIPS EC’s performance on quality measures is broken down into 10 "deciles," with each decile having a value of between 1 and 10 points. CMS then compares a clinician's or group's performance on a quality measure to the performance levels in the national deciles. In other words, the data you submit for each quality measure is compared to a national benchmark in order to determine your Quality score, or number of points achieved for each quality measure. By using benchmarks, CMS is able to compare an EC's performance as it relates to that of their peers. The baseline period for deriving benchmarks will be two years prior to the performance year, which will enable CMS to publish measure benchmarks prior to the start of the relevant performance year. Each measure will typically earn between 3-10 points based on performance compared to a benchmark.

Am I required to report measures for the MIPS Quality Category?

While not required, reporting quality measures within the Quality Category is highly recommended for all CRNAs who are subject to MIPS reporting in 2018, because the baseline Quality weighting is set to 50% of your final MIPS Score in 2018. More importantly, a majority of CRNAs will see an increased weighting of the MIPS Quality Performance Score. This means a significant portion of the Quality Performance Category weight will be used to calculate your final MIPS Composite Score. Due to Performance Category exceptions and/or exemptions, your total performance category score may vary.

CRNAs can check their 2018 MIPS participation status with their National Provider Identification Number (NPI) by using the CMS MIPS Participation Status Tool. The look-up tool displays eligibility information the first determination period (September 1, 2016 through August 31, 2017), and the second determination period (September 1, 2017 through August 31, 2018).

What are the full participation requirements for the Quality Category?

To fully participate in the Quality Performance Category, an eligible clinician (EC) must identify at least six quality measures—one of which is a high priority or outcome measure—and meet the data completeness requirement. Quality measures may be selected from the 2018 MIPS Anesthesia Specialty Measure Set. If fewer than six MIPS measures apply, CRNAs will need to identify alternative non-MIPS measures via a Qualified Clinical Data Registry (QCDR) in order to meet full participation for the Quality category.

To assure data completeness for selected quality measures, individual MIPS eligible clinicians or groups submitting data using QCDRs, qualified registries, or an electronic health record (EHR), must report on at least 60 percent of the MIPS eligible clinician's or group’s patients that meet the measure’s denominator criteria, regardless of payer for the performance period. CRNAs will achieve fewer points in the Quality category if they choose to only partially participate; in other words, if they submit fewer than six measures and/or not meet data completeness.

See Question 4 to learn about how to achieve points. 

How do I achieve points for measures in the Quality Performance Category?

Each quality measure that you choose will be assessed for the minimum 20 case requirement, data completeness threshold of reporting on at least 60% of EC’s or group patients, and measure benchmark set by CMS worth between 3-10 points. Quality measures that have no CMS set benchmark or do not meet the minimum 20 case requirement, will only receive 3 points. If a measure does not meet the 60% data completeness threshold, then only 1 point can be achieved, except for clinicians reporting from small practices (15 or fewer eligible clinicians). Measures that do not meet the data completeness criteria will earn 1 point, except for a measure submitted by a small practice, which will earn 3 points.

How does my performance in the Quality Category affect my final MIPS score?

In 2018, CMS finalized the Quality Category weight at 50% for ECs subject to all four performance categories. However, many CRNAs will be exempt from one or more categories, reweighting their Quality Performance Category weight on their overall MIPS final score. Most CRNAs will find that the Quality performance category will be reweighted to 85% due to multiple CMS exceptions and/or exemptions. 

  • CRNAs will find themselves exempt from the ACI Category, increasing the Quality Category performance weight to 75%. However, should they choose, CRNAs may participate in the ACI category and have their Quality Category weight remain at 50% and ACI weight remain at 25%.
  • CRNAs may likely also have an exception for the Cost Performance Category, normally weighted at 10%. For the 2018 performance period, two measures will be used to calculate the cost performance category score: the Medicare Spending per Beneficiary (MSPB) and total per capita cost measures. The two cost measures are based on case minimums and providers that are mainly involved in evaluation and management services; therefore, many ECs may not have the cost measures attributed to them. If there are no cost measures attributed to the provider, the 10% allocated to the cost category will get re-weighted to the Quality performance category.
  • For CRNAs that have ACI and Cost automatically re-weighted, the Quality performance category will be 85% of the final MIPS composite score.

What is the performance period for the Quality Performance Category?

The MIPS 2018 Performance Period is January 1, 2018 - December 31, 2018 and is the period upon which your 2018 MIPS scores will be based. The reporting period for the quality (and cost) categories run concurrently with the MIPS performance period; therefore, quality measures reporting in 2018 is for the full calendar year which begins on January 1, 2018 and ends December 31, 2018. The deadline for data submission vendors to submit quality data on behalf of MIPS ECs is March 22, 2019.

What are the deadlines for the 2018 MIPS reporting year?

The performance period begins on January 1, 2018 and ends December 31, 2018. To successfully participate in MIPS, CRNAs need to collect data for the reporting period designated for each performance category. For 2018, the Quality performance category reporting period is a full calendar year. CRNAs are encouraged to identify a reporting mechanism such as a Qualified Clinical Data Registry (QCDR) or “traditional” Qualified Registry to meet the 2018 reporting requirements. Once you have chosen your reporting mechanism, your QCDR or Qualified Registry has until March 22, 2019 to submit your quality data to CMS on your behalf.

What factors should I consider when attempting to identify measure for the 2018 MIPS Quality Performance Category?

When selecting measures for reporting, the following factors should be considered:

  • Clinical conditions commonly treated
  • Types of care delivered frequently – preventative, chronic, acute
  • Settings where the care is delivered – office, emergency department, surgical suite
  • Quality improvement goals for the year
  • Other quality reporting programs in use or being considered

It is up to the individual EP or group to determine which measures are eligible to your practice. Modifications to MIPS measure specifications may undergo revisions and updates. CMS provides a list of these changes via the CMS Measure Specifications Manual and Release Notes. CMS states that “All stakeholders should be cognizant of the most up-to-date list and reference it for reporting purposes.” According to the manual a measure will consist of a numerator, denominator, and a rationale. The numerator describes the process or outcome required for performance measurement. The denominator identifies which cases or patient population the measure applies to through codes (e.g., ICD-10, CPT, HCPCS) and additional criteria. For verification purposes, it is important to identify these changes to assure that you, your group, billers, and/or vendors submitting on your behalf are meeting satisfactory reporting based on any updated measure specifications. It is also important to note that not all measures apply to every anesthesia setting or practice. While the AANA has provided a list of potential measures applicable to CRNAs, it is the responsibility of the CRNA to ultimately choose their measure.

The AANA cannot determine which measures may or may not apply to you and your practice. For this reason, the AANA encourages EPs to contact the CMS QualityNet Help Desk at (866) 288-8912 or Qnetsupport@hcqis.org to ensure you are reporting applicable measures.

What anesthesia specific measures are available and where can I find them?

CMS has compiled a 2018 MIPS Anesthesia Specialty Measure Set that CRNAs may choose from. Along with these MIPS measures, CRNAs may seek out additional measures developed by a Qualified Clinical Data Registry (QCDR). A QCDR is defined by CMS as a “CMS-approved entity that collects clinical data on behalf of clinicians for data submission.” Examples include, but are not limited to, regional collaboratives and specialty societies. CRNAs that choose a QCDR need to refer to the respective QCDR for measure specifications. Please refer to the 2018 QCDR list of vendor options.

The table below lists the 2018 MIPS anesthesia-specific measures that CRNAs may choose to report. These 2018 MIPS measures are targeted toward anesthesia providers. Please note that only one (1) out of the 10 CMS 2018 MIPS anesthesia-specific measures can be reported via claims; therefore, this no longer a viable reporting option for CRNAs.

2018 MIPS Anesthesia Measures Table

What 2018 MIPS reporting options can a CRNA choose from?

CRNAs may choose from the following reporting options to submit their quality data as individual EPs:

  • Electronic Health Record (EHR) *if no EHR, check QCDR or QR
  •  CMS-Certified Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey Vendor
  • Qualified Registry
  • Qualified Clinical Data Registry (QCDR)

* Note: only one(1) out the 10 MIPS anesthesia-specific measures can be reported via claims; therefore, claims-based reporting is no longer a viable reporting option for CRNAs who work in traditional anesthesia.

Group practice reporting options for the 2018 MIPS reporting period include:

  • Electronic Health Record (EHR)
  • Qualified Registry
  • QCDR
  • Web Interface (for 25 or more EPs)

What is the difference between a Qualified Registry and a QCDR?

A Qualified Registry (QR) is capable of collecting and submitting MIPS quality data derived from MIPS measures to CMS on your behalf; however, QRs cannot collect and report out on non-MIPS measures. Download the 2018 CMS-approved List of Qualified Registries.

A Qualified Clinical Data Registry (QCDR) is defined by CMS as a “CMS-approved entity that collects clinical data on behalf of clinicians for data submission.” Examples include, but are not limited to, regional collaborative and specialty societies. QCDRs cannot be owned or managed by an individual, locally owned specialty group. The 2018 CMS-approved list of QCDRs can be found on the CMS 2018 MIPS Resource Website.

The QCDR reporting option is different from a qualified registry because it is not limited to MIPS measures within the Quality Payment Program. The QCDR can host up to 30 “non-MIPS” measures approved by CMS for reporting as well. Measures submitted by a QCDR may include measures from one or more of the following categories:

  • Current 2018 QCDR Measures (i.e., CMS approved non-MIPS Measures)
  • Current 2018 MIPS measures
  • Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CAHPS), which must be reported via CAHPS certified vendor
  • National Quality Forum (NQF) endorsed measures
  • Measures used by boards or specialty societies
  • Measures used by regional quality collaborations
  • Other approved CMS measures

Where can I find additional MIPS and Quality Payment Program resources?

For more information on 2018 MIPS please visit the Quality Payment Program Resource Library or contact CMS at qpp@cms.hhs.gov │1-866-288-8292 │TTY: 1-877-715-6222