Scoring the MIPS Quality Category

To understand your potential Merit-based Incentive Payment System (MIPS) payment adjustment in payment year 2019, you’ll want to be familiar with the essential elements of the scoring methodology. If you choose to fully participate in the Quality Payment Program (QPP) under the MIPS payment model, you’ll be reporting on a minimum of six quality measures for the entire year. Each quality measure percentage is converted to a decile which then corresponds to a range of possible points. See table below for an example.

Example of Using Benchmarks for a Single Measure to Assign Points
Decile Sample Quality Measure Benchmarks Possible Points
Decile 1 0 – 6.9% 1.0 – 1.9
Decile 2 7.0 – 15.9% 2.0 – 2.9
Decile 3 16.0 – 22.9% 3.0 – 3.9
Decile 4 23.0 – 35.9% 4.0 – 4.9
Decile 5 36.0 – 40.9% 5.0 – 5.9
Decile 6 41.0 – 61.9% 6.0 – 6.9
Decile 7 62.0 – 68.9% 7.0 – 7.9
Decile 8 69.0 – 78.9% 8.0 – 8.9
Decile 9 79.0 – 84.9% 9.0 – 9.9
Decile 10 85.0 – 100% 10

As long as the submitted data is complete, there is a possibility to earn three to 10 points based upon the percentile-basis performance of that measure relative to national peer benchmarks. The benchmarks, which will be updated by the Centers for Medicare & Medicaid Services (CMS) annually, are available on the QPP website and are based on 2015 Physician Quality Reporting System (PQRS) data. Once you report on six measures, including the required outcome or high priority measure, you have the option to earn additional points. If an Eligible Clinician (EC) or practice reports an additional outcome or patient experience measure, a possible two points can be earned and an additional one point can be earned for each high priority measure. The maximum amount of bonus points an EC can earn is 10% of the total possible points (60 for practices with ≤15 and 70 for practices with ≥16 ECs.

CMS is encouraging ECs to report electronically end-to-end with a bonus point given for each measure reported. To meet the end-to-end reporting criteria, you must use 2014 or 2015 certified electronic health technology (CEHRT) and the data has to come directly from your EHR, with no abstraction allowed.

The table (below) shows you the quality category point breakdown, but let’s look at an example to make it crystal clear:

If a single MIPS measure has a 62% measure performance rate that is better than 60% of peers reflected in the benchmark, then that measure would earn seven out of 10 possible points. See table above.

If all six measures earned seven points each, then the total points would be 6 measures x 7 points = 42 points out of a possible 60 points, or a 42/60 = 70%.

70% x 60% (the weight of the Quality category for CY2017) x 100 = 42. This is your Quality performance score, contributing to the MIPS Final Score.

MIPS provides additional paths to achieve a quality score of 100% by granting bonus points for certain quality reporting activities. So if two bonus points were earned in the example above, then the quality score would increase to (42+2)/60 = 73.3%, resulting in 44 MIPS points. Note that the bonus points are not counted in the quality score denominator (we still divide by the 60-70 possible points from the six measures, not by 62 or 72 points). So it is possible to get a quality score of greater than 100%, in which case the quality score is truncated back down to 100%.

A word about topped out measures, which are measures with a median performance rate of ≥ 95%. Refer back to the benchmarks document to identify the topped out measures. The majority of ECs or practices do well on topped out measures so the most you can earn is three points, since it’s easier to achieve higher performance. However, the non-topped out measures are more difficult to achieve high performance, so it’s a choice you have to make – take the automatic 3 points or try for more. If you find a measure without a benchmark, the maximum amount of points you can earn is three.

The MIPS Calculator is a tool that estimates your reimbursement amount.

MIPS Scoring Methodology


Practices ≥16 ECs
Measure Name Measure Name Performance Points Total Possible Points Potential High Priority Bonus Points Potential CEHRT Bonus Points
Measure 1 Outcome 3 to 10 10 0
(required)
1
Measure 2 High priority 3 to 10 10 0
(required if outcome is N/A)
1
Measure 3 Outcome or
patient experience
3 to 10 10 2 1
Measure 4 High priority 3 to 10 10 1 1
Measure 5 ? 3 to 10 10 ? 1
Measure 6 ? 3 to 10 10 ? 1
All Cause
Hospital
Readmission

(16 + clinicians only with 200 plus instances)1
Claims – no data submission 3 to 10 10 N/A N/A
Total ? 70 ? ?
Cap applied to each bonus category
(10% of total possible points)
Up to 7 Up to 7
Total with high priority and CEHRT bonus Up to 84

1 Medicare Program: MIPS and APM Incentive Under the Physician Fee Schedule and Criteria for Physician-Focused Payment Models

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