MIPS: Quality Measures – Let the Chooser Beware

Jim TateBy Jim Tate, EMR Advocate
MACRA/MIPS Subject Matter Expert
Twitter: @Jimtate, eMail: jimtate@emradvocate.com

For the 2017 MACRA & MIPS reporting year the greatest impact on an Eligible Clinician’s MIPS score will be the Quality Category. CMS provides the following instructions: “Clinicians choose six measures to report to CMS that best reflect their practice. One of these measures must be an outcome measure or a high-priority measure and one must be a crosscutting measure. Clinicians also can choose to report a specialty measure set.” That sounds nifty until you realize there are 271 Measures to select from. Which ones do you choose, especially if you are a specialist?

CMS does make suggestions as to which Measures would be clinical relevant based on the provider type, but it comes with a disclaimer: “This resource provides a non-exhaustive sample of measures that may apply to ophthalmologists. Make sure to consider your reporting method, practice size, patient mix, and performance period to choose the measures that best suit you.”

Let’s take a look at the CMS document that suggests clinically relevant Measures for Ophthalmologists.

  • Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery
  • Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery
  • Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement
  • Age-Related Macular Degeneration (AMD): Dilated Macular Examination
  • Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy)
  • Cataract Surgery: Difference Between Planned and Final Refraction
  • Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery
  • Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures
  • Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery
  • Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery
  • Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
  • Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy
  • Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation
  • POAG: Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care

While all the Measures might be relevant to the practice of an Ophthalmologist you will notice I have bolded four of them. These are not considered “High Priority” and will not provide a boost to the final MIPS score. Here is the bottom line: to maximize the potential point value of your selected Quality Measures do not accept what is being offered on a silver plate by CMS. The issue of “MIPS friendly” vs. “clinically relevant” measure selection must be addressed if the desire is to promote the achievement of a high MIPS score. Avoid those Measures that are not of high value. Avoid those Measures that are topped out and only offer a maximum of 3 points. A decile system is used for the Measures and so scoring 70% on one Measure will not necessarily give you the same points on another Measure. There is a lot going on in the selection of which Measures to report. A proper strategy for selection is the most important thing you can do. The submission process is a close second and we will review that in the next post.

This article was originally published on MIPS Consulting Blog and is republished here with permission.