Clinical Quality Measures for
MIPS Reporting Period 2022

Requirements:

  • 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.

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)
  • 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-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

Scoring

  • 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

Bonus 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.

 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 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

Telehealth Eligible

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

Other Measures

eCQM / NQF ID

Telehealth Eligible

7 Point Cap
Preventive Care and Screening: Screening for Depression and Follow-Up Plan CMS2v11 / None Yes No
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan CMS69v10 / None No No
Cervical Cancer Screening CMS124v10 / None Yes No
Breast Cancer Screening CMS125v10 / None Yes No
Pneumococcal Vaccination Status for Older Adults CMS127v10 / None Yes No
Colorectal Cancer Screening CMS130v10 / None Yes No
Diabetes: Eye Exam CMS131v10 / None Yes No
Diabetes: Medical Attention for Nephropathy CMS134v10 / 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) CMS135v10 / 0081e Yes No
Follow-Up Care for Children Prescribed ADHD Medication (ADD) CMS136v11 / None Yes No
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention CMS138v10 / 0028e Yes No
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) CMS144v10 / 0083e Yes No
Preventive Care and Screening: Influenza CMS147v11 / 0041e Yes No
Dementia: Cognitive Assessment CMS149v10 / 2872e Yes No
Chlamydia Screening for Women CMS153v10 / None Yes No
Weight Assessment & Counseling for Nutrition & Physical Activity for Children and Adolescents CMS155v10 / None Yes No
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease CMS347v5 / None Yes No