Practice Scenario: Partial Participation

Pick Your Pace

Practice Scenario: Partial Participation

Pick Your Pace Practice Scenario #2: Partial Participation

Dr. Smith is a family physician in a medium-sized practice and has been reporting the diabetes measures group under the Physician Quality Reporting System (PQRS) using a qualified registry. Dr. Smith is interested in participating in the Merit-based Incentive Payment System (MIPS) track of Medicare’s Quality Payment Program (QPP), but is not ready to report all performance categories. She’d like to continue reporting quality measures to ensure her processes are working effectively. How should she begin participating in QPP?


Dr. Smith can avoid the 2019 negative payment adjustment by reporting measures similar to those she previously submitted for PQRS. Measures groups are not available for reporting under MIPS, but the individual measures that were part of the diabetes measures group are available. Reporting these measures for patients she sees throughout a continuous 90-day period will allow Dr. Smith to avoid the negative payment adjustment and possibly earn a small positive payment adjustment. This will also help her gauge her readiness for full reporting in 2018. Dr. Smith can continue using a qualified registry as her reporting mechanism. To earn more than the 3-point minimum for measure submission, she will need to report on at least 50% of patients (regardless of payer) and have at least 20 patients that qualify for the measures.

1. Dr. Smith visits the QPP website’s list of quality measures( She filters the list by “Data Submission Method” and selects “Registry” from the drop down list

partial participation screenshot #1

2. Since Dr. Smith wishes to report on the same diabetes measures as in the past, she downloads and reviews the measure specifications for those measures to familiarize herself with any changes. Specifications can be found in the “Quality Measures Specifications” file on the QPP Education Resources( webpage.

partial participation screenshot #2

3. Dr. Smith reviews the list of qualified registries posted on the QPP website and selects a vendor. She contacts the registry she plans to use, and discusses options and requirements for submitting data with the vendor. Dr. Smith learns the registry accepts quality data codes (QDCs), billing files, and/or EHR data. She reviews the numerator, denominator, and exclusion codes for each measure to ensure that she is documenting the correct codes. She uses the “Individual Measure Flow” diagrams with the measure specifications to assist in reporting on the correct patients.

4. Dr. Smith’s patient, Jane, comes to the clinic. She is 55 and has diabetes. Jane has private insurance. Since the practice is now reporting on all patients, regardless of payer, the nurse recognizes that this patient is now eligible for the quality measures the practice has chosen to report. The nurse flags the patient to alert Dr. Smith.

6. Dr. Smith conducts her exam and enters the necessary documentation for the selected quality measures and includes appropriate codes.

7. At the end of the MIPS performance period, Dr. Smith works with the registry to run reports to identify all patients that met the numerator, denominator, and exclusion criteria for each measure she selected. She uploads this information in accordance with the registry instructions. The registry, in turn, submits the information to the Centers for Medicare and Medicaid Services (CMS) on behalf of Dr. Smith.


Reporting at least one measure will protect Dr. Smith from the 2019 negative payment adjustment. Reporting additional measures will help increase her practice’s score in the quality performance category, which accounts for 60% of the physician’s final score in 2017. Dr. Smith can report more than six measures. However, the six with the highest performance are the ones that count towards her quality category score. The more quality measures she reports that meet the data completeness criteria, the higher her score will be, and the higher her potential for a positive payment adjustment.

Each quality measure submitted will receive a baseline of three points. Measures reported for a continuous 90 days, for at least 20 patients, and include 50% of the denominator-eligible patients will be scored on performance. Performance will be compared to a benchmark and awarded 3 to 10 points. Download the 2017 quality measure benchmarks »(

Earning Additional Points

Dr. Smith could increase her MIPS final score by reporting measures and earning points in the improvement activities (IA) or advancing care information (ACI) performance categories. Each of these categories has specific requirements.

  • To earn points in the IA category, Dr. Smith must attest to having performed at least one activity for a minimum of 90 days in 2017. Please see the QPP Improvement Activities( webpage for a list of improvement activities.
  • To earn points in the ACI category, Dr. Smith must attest to at least the four required ACI measures in 2017. Additional points can be earned for a high performance on ACI required and optional measures. Please see the QPP Advancing Care Information( webpage for a list of ACI measures.

Other Options and Preparing for the Future

Dr. Smith could choose to report using a qualified registry mapped to her EHR, a qualified clinical data registry (QCDR), or EHR-based reporting. These options have the capacity to provide ongoing feedback reports throughout the performance period and better support performance improvement efforts. Dr. Smith can use different reporting methods among different categories. However, she must use one data submission mechanism per performance category for all the measures reported in that category.

Dr. Smith should begin working with her selected registry early in the year to ensure the practice captures needed data through appropriate documentation.