Clinical Quality Measures for
MIPS Reporting Period 2021

Requirements

  • Submit collected data for at least 6 measures, including 1 outcome or high-priority measure in absence of an applicable outcome measure, or a complete specialty measure set.
  • If you choose to submit a specialty measure set, you must submit data on at least 6 measures within that set. If the set contains fewer than 6 measures, you should submit each measure in the set.
  • Performance Period is for 12 months (January 1st – December 31st)

Collection Type

You can submit measures from different collection types (except CMS Web Interface measures) to fulfill the requirement to report a minimum of 6 quality measures.

  • CMS Web Interface (Group of 25 or more) (NOTE: Will not be available for CY 2022 and beyond)
  • eCQMs (Electronic Clinical Quality Measures)
  • Medicare Part B Claims (Small Practice ONLY – defined as 15 or fewer)
  • MIPS CQMs (MIPS Clinical Quality Measures)
  • QCDR (Qualified Clinical Data Registry Measures)

Submission Types

There are 4 submission types you can use for quality measures:

  • Medicare Part B Claims: Small Practice Only
  • Sign-In and Upload
  • CMS Web Interface: Group of 25 or more
  • Direct submission via Application Programming Interface (API): For 25 or more clinicians and Third-party Intermediary

Scoring

  • 40% of Final Score (This percentage can change due to Exception Applications or APM Entity participation)

 Scoring Policies for Quality Measures:

  • Each measure submitted will be scored on a scale from 3-10 or 3-7 for Topped-out measures that meet all the following criteria: Has a benchmark; Meets Case Minimum (20); Meets Data Completeness (70%)
  • Measures that are submitted and meet data completeness, BUT do not have either a benchmark or meets case minimum will be awarded 3 points
  • Measures that are submitted BUT do not meet data completeness, even if the measure has a benchmark and/or meets the case minimum:
    • Small Practice will receive 3 points for the measure
    • Large Practice will receive 0 points for the measure

NOTE: Benchmarks are set from historical data (from 2 years prior). When a historical benchmark can’t be created, CMS will attempt to create a benchmark using data submitted for the performance period.

 Bonus Points:

  • Report on additional Outcome or High Priority measures beyond the required 1:
    • Outcome measure = 2 bonus points
    • High Priority measure = 1 bonus point
  • Quality measures submitted thru EHR reporting
    • 1 Point for each measure submitted
  • Small Practice Bonus (15 EC or less)
    • 6 bonus points will be added to the quality category for clinicians in small practices who submit at least 1 measure, either individually or as a group or virtual group. This bonus is not added to clinicians or groups who are scored under facility-based scoring.

 Improvement Scoring:

  • Will be based on the rate of improvement such that higher improvement results in more points for those who have not previously performed well.
  • Improvement will be measured at the performance category level.
  • Up to 10 percentage points available.

Outcome Measures

eCQM / NQF ID

Telehealth Eligible

7 Point Cap
Children Who Have Dental Decay or Cavities CMS75v9 / None Yes Yes
Diabetes: Hemoglobin A1c Poor Control CMS122v9 / None Yes No
Controlling High Blood Pressure CMS165v9 / None Yes No

High Priority Measures

eCQM / NQF ID

Telehealth Eligible

7 Point Cap
Closing the Referral Loop: Receipt of Specialist Report CMS50v9 / None Yes No
Documentation of Current Medications in the Medical Record CMS68v10 / 0419e Yes Yes
Functional Status Assessment for Congestive Heart Failure CMS90v10 / None Yes No
Screening for Future Falls Risk CMS139v9 / None Yes No
Appropriate Testing for Pharyngitis CMS146v9 / None Yes No
Appropriate Treatment for Upper Respiratory Infection (URI) CMS154v9 / None Yes No
Use of High-Risk Medications in Older Adults CMS156v9 / None Yes Yes

Other Measures

eCQM / NQF ID

Telehealth Eligible

7 Point Cap
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan CMS69v9 / None No No
Cervical Cancer Screening CMS124v9 / None Yes No
Breast Cancer Screening CMS125v9 / None Yes No
Pneumococcal Vaccination Status for Older Adults CMS127v9 / None Yes No
Colorectal Cancer Screening CMS130v9 / None Yes No
Diabetes: Eye Exam CMS131v9 / None Yes No
Diabetes: Medical Attention for Nephropathy CMS134v9 / None Yes No
Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD) CMS135v9 / 0081e Yes No
Follow-Up Care for Children Prescribed ADHD Medication (ADD) CMS136v10 / None Yes No
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention CMS138v9 / 0028e Yes No
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) CMS144v9 / 0083e Yes No
Preventive Care and Screening: Influenza CMS147v10 / 0041e Yes No
Dementia: Cognitive Assessment CMS149v9 / 2872e Yes No
Chlamydia Screening for Women CMS153v9 / None Yes No
Weight Assessment & Counseling for Nutrition & Physical Activity for Children and Adolescents CMS155v9 / None Yes No