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The Quality category accounts for the largest proportion of the Merit-Based Incentive Payment System (MIPS) Composite Score for performance year 2021 – 40% for non-hospital-based clinicians and 65% for hospital-based or other clinicians who may be exempt from the Promoting Interoperability (PI) category. As a result, eligible clinicians should be sure to consider strategies for maximizing their performance under this category for 2021.

Reporting Requirements and Scoring Rules

For 2021, clinicians must report on at least six quality measures—either from the MIPS clinical quality measure inventory or measures offered by specialty-specific Qualified Clinical Data Registries (QCDRs). Reported measures must include one outcomes measures or another high-priority measure (appropriate use, patient safety, efficiency, patient experience, or care coordination) if an outcomes measure is not available. As in the past, clinicians must report on each measure for 70% of applicable patients (Medicare-only for claims reporting; all-payer data for qualified registry, QCDR, and EHR reporting) over the calendar year. Each quality measure is generally worth up to 10 performance achievement points, except in the following situations: 

  • Clinicians who report a measure, but do not meet the data completeness criteria of 70% will receive 0 out of 10 points for that measure (note that clinicians in small practices will receive 3 points). 
  • Clinicians who meet data completeness on a measure but do not meet the case minimum for 20 patients can only earn up to 3 points on the measure. 
  • Clinicians who report on a measure that does not have an historic or performance year benchmark are only eligible to receive 3 points on the measure.
  • Certain measures that demonstrate "topped out" performance for two consecutive years, meaning that performance on these measures has been high and unvarying, are subject to a 7-point scoring cap. Clinicians with perfect performance on these measures can earn no more than 7 points. 

The historic benchmarks that will be used to evaluate performance on MIPS quality measures in 2021 are available for download here. The historic benchmark file indicates which measures lack benchmarks and which are subject to the 7-point topped out scoring cap. 

If clinicians or groups report on more than six measures, CMS will use the top six performing measures to calculate a quality score. However, 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. 

Clinicians are also eligible for up to 10 performance improvement points, which are added to their total Quality category score, if their Quality category score improves from year-to-year.

Available Quality Measures 

Linked below are some recommended claims- and registry-based MIPS measures that cardiothoracic surgeons might find applicable to their practices. These lists are based on CMS MIPS specialty measure sets, which are suggested sets of 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. 

Keep in mind that claims-based reporting is only available to clinicians in small practices (15 or fewer eligible clinicians), whether reporting individually or as a group. 

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 (note that this tool does not include QCDR measures). 

When selecting measures, it is important to consider whether they are subject to any scoring caps that would impact your final performance score. Again, the historic benchmarks that will be used to evaluate performance on MIPS quality measures in 2021 are available for download here

Additionally, for group practices with more than 15 MIPS-eligible clinicians, CMS automatically will calculate a new Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate measure based on administrative claims. MCS 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. 

The 2021 measure specifications of MIPS clinical quality measures, as well as QCDR measures, are available for download through QPP Resource Library.

Last updated: 6/17/2021