MIPS Measures Reference Guide
MIPS Measures Reference Guide
2017 MIPS Quality Measures
The Merit-based Incentive Payment System (MIPS) track of Medicare’s Quality Payment Program (QPP) includes four performance categories: quality, cost, improvement activities, and advancing care information (ACI). The quality performance category requires clinicians to report on six measures, including at least one outcome measure. Since most family physicians will initially participate in MIPS, and therefore are required to report quality measures, it is important they select measures appropriate for their practice needs and capabilities. The 2017 MIPS Quality Measures spreadsheet(2 MB XLSX) provides information to assist physicians in reviewing and selecting MIPS quality measures.
Note: after you click on the spreadsheet and before you begin reviewing measures, click on the READ ME tab of the spreadsheet for additional information.
In the spreadsheet, the measure title (column A) and measure description (column F) columns provide high-level information for each measure. The quality ID number (column C) is assigned by the Centers for Medicare & Medicaid Services (CMS), and is a cross reference to detailed information, such as measure specifications and benchmark files. The National Quality Forum (NQF) number (column B) is also shown if the measure has been endorsed as meeting criteria for reliability, validity, importance, feasibility, and other NQF standards. The NQF number is frequently mentioned in quality measure discussions.
Measures Applicable to Family Medicine and Reliable Scoring
The measures spreadsheet includes all 271 MIPS quality measures. Measures in white cells are included in the MIPS General Practice/Family Medicine Specialty Set to help you narrow down the list to family medicine measures. The column titled core quality measure (column D) indicates (with ‘x’) whether or not the measure is also included in the Accountable Care Organization (ACO)/Patient-Centered Medical Home (PCMH)/Primary Care Core Measure Set. For measures to receive a performance score in MIPS, they must have a minimum of 20 cases. Family physicians are likely to have at least 20 cases for these measures, allowing the measure to be reliably scored to earn up to 10 points per measure. Measures outside the family medicine set are greyed-out, but still may be selected, if desired.
Column G shows the measure type. MIPS require physicians to report at least one outcome or intermediate outcome measure to fully meet quality category requirements. Other measure types include: process, structure, efficiency, and patient engagement/experience.
Columns H through L indicate the reporting method available for each measure: claims, electronic health record (EHR), CMS Web Interface, qualified registry, or other (CAHPS and administrative claims). Qualified clinical data registry (QCDR) measures are not included because QCDRs are not limited to offering measures for reporting that are only included in the MIPS final list of measures. Clinicians using a QCDR should work directly with their vendor to identify appropriate measures. Columns I and J show identifiers for EHR and CMS Web Interface measures frequently used by EHR vendors. These are used in other references as well, and are used either instead of, or in addition to, the CMS quality ID listed in column C.
Measures that are topped out in 2017 are highlighted in yellow. Though topped-out measures are treated the same as other measures in 2017, in future years, CMS may remove these measures, limit the number that can be reported, or score them differently (e.g., lower) than other measures.
Measures Eligible for Bonus Points
High-priority measures are eligible for bonus points under MIPS scoring. The number of bonus points available to individual measures is shown in column M. Bonus points are not awarded for reporting the first required outcome measure, but are available for each additional outcome measure reported. There is a cap to the number of bonus points available.
Sorting and Filtering Data in the Spreadsheet
Each column has a filter (grey icon with an arrow) as part of the column label. You may click on these filters to sort data, and include or exclude certain values using the drop-down menu. The spreadsheet is currently sorted with family medicine specialty measures first, then by quality ID. You may clear all filters by selecting “home,” then the “sort and filter” drop-down menu, then “clear.”
Measure specifications are detailed descriptions and instructions for each measure, and include definitions of the action/outcome required (numerator), population being measured (denominator), exceptions/exclusions to the measure, measure codes, and other details needed to correctly collect data and report the measure. Specifications differ by reporting method and can be found below:
- electronic Clinical Quality Measures (eCQMs)(ecqi.healthit.gov)
- Claims, registry, and CMS Web Interface(qpp.cms.gov) (Note: zip file takes several minutes to download)
A benchmark is a point of reference against which measures may be compared or assessed. CMS has calculated an array of benchmarks for each quality measure, broken down into deciles. Points are assigned based on where your performance falls within the benchmarks. Benchmarks vary depending on method of reporting, and can be found at below:
- Claims, registry/QCDR, and EHR(qpp.cms.gov) (Note: zip file takes several minutes to download)
- Quality Measure Benchmarks for the 2016 and 2017 Reporting Years(www.cms.gov)