Clinical Quality Measures for
MIPS Reporting Period 2022
- 12-Month Reporting Period (January 1st-December 31st)
- Report on 6 Individual Measures – 1 must be an outcome measure OR a high-priority measure (if an outcome is not available)
- OR you report all 10 CMS Web interface measures (Groups Only)
- 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.
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)
- 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)
There are 4 submission types you can use for quality measures:
- Medicare Part B Claims: Small Practice Only-CMS would calculate a group-level quality score from claims if the practice submitted data for another performance category as a group, signaling their intent to participate as a group.
- 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
- 30% of Final Score
Scoring Policies for Quality Measures:
Existing Measures – That have a historical benchmark, or a performance period benchmark, meets data completeness (70%) and case volume (20) will be scored on a scale from 3-10 or 3-7 for Topped-out measures (does not apply to New measures)
- Measures without a benchmark (historical or performance period) will earn 3 points
- Measures that do not meet case volume will earn 3 points
- Measures that do not meet data completeness:
- Small practice earns 3 points
- Large practice earns 0 points
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.
New Measures – When a performance period benchmark can be created, and data completeness (70%) and case volume (20) is met:
1st Year: Measure will be scored on a scale from 7-10 points
2nd Year: Measure will be scored on a scale from 5-10 points
If a performance period benchmark cannot be established and/or case volume was not met:
1st Year: Measure will earn 7 points
2nd Year: Measure will earn 5 points
- 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.
NOTE: Bonus points for reporting on additional Outcome or High-priority measures and end-to-end reporting have been removed from 2022 performance year.
- 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.
eCQM / NQF ID
7 Point Cap
|Children Who Have Dental Decay or Cavities||CMS75v10 / None||No||Yes|
|Diabetes: Hemoglobin A1c Poor Control||CMS122v10 / None||Yes||No|
|Depression Remission at Twelve Months||CMS159v10 / None||Yes||No|
|Controlling High Blood Pressure||CMS165v10 / None||Yes||No|
High Priority Measures
eCQM / NQF ID
7 Point Cap
|Closing the Referral Loop: Receipt of Specialist Report||CMS50v10 / None||Yes||No|
|Documentation of Current Medications in the Medical Record||CMS68v11 / None||Yes||Yes|
|Functional Status Assessment for Congestive Heart Failure||CMS90v11 / None||Yes||No|
|Screening for Future Falls Risk||CMS139v10 / None||Yes||No|
|Appropriate Testing for Pharyngitis||CMS146v10 / None||Yes||No|
|Appropriate Treatment for Upper Respiratory Infection (URI)||CMS154v10 / None||Yes||No|
|Use of High-Risk Medications in Older Adults||CMS156v9 / None||Yes||Yes|