Quality Component of the MIPS Composite Score

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The Quality category accounts for the largest proportion of the Merit-Based Incentive Payment System (MIPS) Composite Score for performance in 2017 – 60% for non-hospital-based clinicians and 85% for hospital-based or other clinicians who may be exempt from reporting under the ACI category. As a result, eligible clinicians should be sure to consider strategies for maximizing their performance under this category.

The STS National Database continues to serve as the most efficient portal for cardiothoracic surgeons participating in the Adult Cardiac Surgery Database to gain credit for the quality reporting components of MIPS.

Using the STS National Database for MIPS Quality Reporting

If not using the STS National Database for quality reporting to CMS, cardiothoracic surgeons must report on at least six quality measures from the MIPS inventory. Reported measures must include one outcomes measure or another high-priority measure (appropriate use, patient safety, efficiency, patient experience, or care coordination) if an outcomes measure is not available. To receive a performance score on a reported measure, clinicians must report on each measure for 50% of applicable patients (Medicare-only for claims reporting; all-payer data for qualified registry, Qualified Clinical Data Registry, and electronic health record [EHR] reporting) over at least a 90-day period and have at least 20 applicable patients for a given measure.

Linked below are some recommended claims- and registry-based MIPS measures that cardiothoracic surgeons might find applicable to their practices. The MIPS measure search tool also may be used to determine what measures are most relevant to a cardiothoracic surgical practice and which measures are considered outcome or other high-priority measures. You can download more detailed measure specifications.

Additionally, for group practices with more than 15 MIPS-eligible clinicians, CMS automatically will calculate a 30-day all-cause hospital readmission measure based on administrative claims. CMS will only score a group practice on this measure if at least 200 cases are attributed to the group based on the measure specifications. This measure requires no additional data submission on the part of the practice.

Eligible clinicians also may elect to use a “specialty measure set” if one is available. Measure sets are simply suggested subsets of MIPS measures that CMS believes are most applicable to a specific specialty. Although many specialty sets include more than six measures, clinicians relying on these sets are only required to report on up to six measures. If a specialty measure set has fewer than six measures reportable via a specific reporting mechanism, a clinician relying on that set would only be expected to report on the available measures.

For example, CMS has provided a Thoracic Surgery Specialty Measure Set that includes 15 measures, of which only five are reportable via EHR. If a thoracic surgeon opts to report quality measures via an EHR and relies on this set, he or she would be required to report on only those five measures. If clinicians or groups report on more than six measures, CMS will use the top six performing measures to calculate a quality score. Clinicians/groups can earn bonus points for reporting additional outcome and high-priority measures beyond the base requirement or for using end-to-end electronic reporting.

Recommended Measures for Quality Reporting – Cardiac Surgery
Recommended Measures for Quality Reporting – Thoracic Surgery

Last updated: 5/16/2017