2020 mips quality performance category
Post on 17-Mar-2022
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2020 Quality Performance Category
Reweighting
45% final Score
(for CRNAs reporting
PI* with applicable Cost
Measures)
70% final Score
(for CRNAs NOT
reporting PI*, but with
applicable Cost
Measures)
85% of final score
(for CRNAs NOT
reporting PI* with NO
applicable Cost
Measures)
*PI: Promoting Interoperability
APR2020 3
Quality Performance Category
• Replaced the Physician Quality Reporting System
(PQRS)
• Measures health care processes, outcomes and patient
experiences of their care
• Make up the largest part (45%) of the MIPS Final Score
• CRNAs can report Quality data as individuals or as part
of groups
• Data is collected for the entire calendar year (January 1st
through December 31st)
APR2020 4
MIPS 2020 Full Participation
Requirements
Category weight = 45% Reweight = 70% (not reporting PI)
Reweight = 85% (no PI/Cost)
What you need to do
For all CRNAs: Report on at 6 applicable measures including 1 outcome or high priority measure for at least 70% of ALL your patients for FULL calendar year
Performance Category
Subject to
Reweight
QUALITY-- 45%
APR2020
2020 Anesthesia MIPS Quality Measures
6
08FEB2019
ID# Measure Title Measure Type High Priority
44 Coronary Artery Bypass Graft (CABG): Preoperative Beta-locker in Patients with Isolated CABG Surgery
Process No
76 Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections
Process Yes
404 Anesthesiology Smoking Abstinence IntermediateOutcome
Yes
424 Perioperative Temperature Management Outcome Yes
430 Prevention of Post-Operative Nausea and Vomiting (PONV)-Combination Therapy—Adults
Process Yes
463 Prevention of Post-Operative Vomiting (POV)-Combination Therapy—Pediatrics
Process No
477* Multimodal Pain Management Process Yes
*New measure for 2020
APR2020
Quality Data Collection Types
The six collection types for Quality Measures are:
• Electronic clinical quality measures (eCQMs)
• MIPS Clinical Quality Measures (CQMs)
• Qualified Clinical Data Registry (QCDR) measures
• Medicare Part B measures
• CMS Web Interface measures
• The Consumer Assessment of Healthcare Providers and
Systems (CAHPS) for MIPS Survey*
https://qpp.cms.gov/mips/how-to-register-for-CMS-WI-and-CAHPS
APR2020 7
Quality Measure Benchmarks
• Benchmarks are specific to the collection type.
• CMS awards between 3 and 10 points for each measure
in the Quality performance category.
• The measure points awarded are based on a benchmark
calculated from previous data. Benchmark data is
available on the CMS Quality Payment Program website.
• New measures that do not have a benchmark will be
awarded only 3 points.
8
08FEB2019
APR2020
Qualified Clinical Data Registry (QCDR)
Reporting May Be a Better Option for
MIPS
QCDRs
• Allows CRNAs to fulfill the Quality Category requirements with anesthesia QCDR measures
AND
• Provides opportunities for
completing and attesting
to several Improvement
Activities
Claims/EHR/Registry
• CRNAs are limited to MIPS measures for meeting the QualityCategory requirements
AND
• CRNAs will have to find
appropriate activities to fulfill
the Improvement Activities
Category
APR2020
Data Completeness and Bonus Points
• The small practice bonus is 6 points for MIPS ECs who
submit data for at least one quality measure. The bonus
will be added to the Quality performance category score.
• Small practices can receive up to 3 points for reporting
quality measures that do not meet data completeness
requirements (reporting on least 70% of all patients).
• Two bonus points can be awarded for reporting outcome
and patient experience measures.
• One point can be awarded for other high-priority
measures that meet data completeness and case
minimum requirements.
11
08FEB2019
APR2020
Additional Resources
• Quality Payment Program website: https://qpp.cms.gov
• QPP Resource Library:
https://qpp.cms.gov/about/resource-libary
• 2020 Quality Quick Start Guide
• Technical Assistance: https://qpp.cms.gov/about/help-
and-support
• E-mail: QPP@cms.hhs.gov
• Phone: 1-866-288-8292 (Monday through Friday)
APR202012
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