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The Quality category in MIPS provides a variety of reporting flexibilities. There are reporting options and collection types to consider. The Quality category is intended to measure Quality performance based on certain measures. Most providers are most familiar with Traditional MIPS and APP Reporting (reporting with an ACO).
MIPS Quality reporting covers a 12 month performance period (full calendar year January 1-December 31, 2024)
Traditional MIPS, established in the first year of QPP, is the original reporting option for MIPS. You select the quality measures and improvement activities that you'll collect and report from all of the quality measures and improvement activities finalized for MIPS. You’ll also report the complete Promoting Interoperability measure set, if you are required to report MIPS and the PI category and do not have an existing exclusion. The QPP collects and calculates data for the cost performance category for you.
General reporting requirements are as follows:
- You’ll need to submit collected data for at least 6 quality measures (including one outcome measure or high priority measure in the absence of an applicable outcome measure), or a complete specialty measure set.
- New for 2024: Beginning with the 2024 performance period, you’ll need to report performance data for at least 75% of the denominator eligible cases for each quality measure (data completeness), which is an increase from the previous data completeness threshold of 70%.
- You can submit measures from different collection types to fulfill the requirement to report data for at least 6 quality measures.
You may supplement Claims Based measure collection .
MIPS Value Pathways (MVPs) are the newest reporting option that offer clinicians a subset of measures and activities relevant to a specialty or medical condition. MVPs offer more meaningful groupings of measures and activities, to provide a more connected assessment of the quality of care. You’ll select, collect, and report on a reduced number of quality measures and improvement activities (as compared to traditional MIPS). You’ll also report the complete Promoting Interoperability measure set (the same as reported in traditional MIPS), if you are required to report MIPS and the PI category and do not have an existing exclusion. The QPP collects and calculates data for the cost performance category and population health measures for you. MVPs must be pre-registered for in the QPP portal during the calendar year (you can not elect MVPs to report on in Q1 2025 during reporting). A new MVP measure set includes a Value in Primary Care measure bundle that is the most relevant and currently the only MVP bundle supported by Elation. To report on an MVP measure set you must select 4 quality measures from the measure bundle offered. The
bolded measures and collection types are the measures that are available for the Value in Primary Care MVP:
- Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)
- Collection Type: Medicare Part B Claims Measure Specifications, eCQM Specifications, MIPS CQMs Specifications
- Advance Care Plan
- Collection Type: Medicare Part B Claims Measure Specifications, MIPS CQMs Specifications
- Preventive Care and Screening: Screening for Depression and Follow-Up Plan
- Collection Type: Medicare Part B Claims Measure Specifications, eCQM Specifications, MIPS CQMs Specifications
- Controlling High Blood Pressure
- Collection Type: Medicare Part B Claims Measure Specifications, eCQM Specifications, MIPS CQMs Specifications
- Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
- Collection Type: eCQM Specifications
- CAHPS for MIPS Clinician/Group Survey
- Collection Type: CAHPS Survey Vendor
- Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
- Collection Type: eCQM Specifications, MIPS CQMs Specifications
- HIV Screening
- Collection Type: eCQM Specifications
- Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM)
- Collection Type: MIPS CQMs Specifications
- Screening for Social Drivers of Health
- Collection Type: MIPS CQMs Specifications
- Adult Immunization Status
- Collection Type: MIPS CQMs Specifications
- Preventive Care and Wellness (composite)
- Collection Type: MIPS CQMs Specifications
- Initiation, Review, And/Or Update To Suicide Safety Plan For Individuals With Suicidal Thoughts, Behavior, Or Suicide Risk
- Collection Type: MIPS CQMs Specifications
- Register in the QPP portal
- Select one population health measure during registration. CMS will calculate these measures through administrative claims and will be scored as part of the quality performance category.
- For the 2024 performance period, there are 2 population health measures proposed to be available for selection:
- Hospital-Wide, 30-day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups
- Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions
- Quality Performance Category
- Select and submit 4 quality measures
- Improvement Activities Performance Category
- Select and submit 2 medium-weighted improvement activities OR one high-weighted improvement activity.
- Promoting Interoperability Category
- Do not need to submit data if you have an existing exclusion (small practices with 15 or fewer providers)
The Alternative Payment Model (APM) Performance Pathway (APP) is a streamlined reporting option for clinicians who participate in a MIPS APM. The APP is designed to reduce reporting burden, create new scoring opportunities for participants in MIPS APMs, and encourage participation in APMs. You’ll report a predetermined measure set made up of quality measures in addition to the complete Promoting Interoperability measure set (the same as reported in traditional MIPS), if you are required to report the PI category and do not have an existing exclusion (example, you are not in a small practice). MIPS APM participants currently receive full credit in the improvement activities performance category.
If you participate in an ACO/APM reach out to that APM administrator to understand how to report MIPS with the ACO or other APM. ACOs and other APMs get full credit for Improvement Activities and the only reporting requirement for APM participants is the Quality category which is reported as a whole (with the ACO/APM).
- Electronic Clinical Quality Measures (eCQMs)
- eCQMs are standardized measures that a Certified EHR Technology (CEHRT) meets to specification and is certified to. There are currently 43 eCQMs available to report to MIPS in 2024. Elation is certified to 10 eCQMs, and 7 eCQMs are eligible for Traditional MIPS reporting. eCQMs are measured as part of your regular workflows and can be found regularly in the Quality Dashboard of Elation. During reporting, eCQMs are extracted as a QRDA file and submitted to the QPP. (QRDA files and eCQMs are used and submitted to other CMS programs as well).
- These are the eCQMs that Elation supports in 2024 (7 bolded eCQMs that contribute to traditional MIPS and the total 10):
- MIPS Clinical Quality Measures (CQMs)
- MIPS CQMs are often collected by third party intermediaries and submitted on behalf of MIPS eligible clinicians. You may choose to work with a Qualified Registry.
- Medicare Part B Claims Measures
- This collection type is only available to those designated with the small practice special status (15 or fewer clinicians). Medicare Part B claims measures are always reported with the clinician’s individual (rendering) NPI even when reporting as a group, subgroup (MVPs only) virtual group (traditional MIPS), or APM Entity. For more information about reporting quality measures through Medicare Part B claims, download this guide from the QPP.
Elation supports 10 eCQMs, 7 of which count in Traditional MIPS, and 2 are used in the MVP Value in Primary Care group. Administrative Claims Based measures may be selected to support additional measure selections for MIPS to report for Traditional MIPS and MVPs. Elation supports APM reporting with the selected eCQMs, and other measures supported depending on collection type.
- Traditional MIPS: You may report using 6 eCQMs or a combination of eCQMs and claims based measures, or reporting through a registry. To report through a registry, we recommend connecting with MDInteractive.
- MVPs: You may report on the Value in Primary Care MVP the 4 bolded measures above which include 2 eCQMs and 2 Claims Based Measures.
- APP: If you have signed up with an APM to participate this year, such as an ACO, or REACH, ensure your quality reporting is aligned with the measures they selected and only one quality submission is required, the quality submission reported with your APM.
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