A Complete Guide to MIPS Quality Measures

A Complete
Guide to
MIPS Quality
Measures
Rachel Katz
Darren O’Brien

© 2020 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
A Complete Guide to MIPS Quality Measures
This guide includes 12 frequently asked questions about Merit-based Incentive
Payment System (MIPS) quality measures. Use these 12 questions and answers to
increase your understanding of MIPS quality measures and choose the best MIPS
quality measures for your team.
1. Where can MIPS participants find a list of MIPS
quality measures?
2. What are specialty measure sets and how do they
categorize MIPS quality measures?
3. What are submission methods for MIPS quality
measures?
4. How are denominators calculated for MIPS quality
measures?
5. How are numerators calculated for MIPS quality
measures?
6. How are benchmarks used to score your
performance in MIPS quality measures?
7. Other than benchmarks, what does CMS use to
score your performance in MIPS quality measures?
8. What is the burden of different MIPS quality
measures?
9. What is the documentation burden of different MIPS
quality measures?
10. What is a measure steward for MIPS quality
measures?
11. What evidence do measure stewards use to create
MIPS quality measures?
12. What are the types of MIPS quality measures?

#1 ̶ Where Can I Find the Full List of MIPS Quality Measures?
Download the full list of MIPS 2020 quality measures
from Able Health™.
After downloading the list, you can filter by specialty-
measure set, submission method, measure steward,
measure type, and more (figure 1).
Not familiar with specialty-measure sets, measure
stewards, and measure types? Keep reading and
learn everything you need to know.

#1 ̶ Where Can I Find the Full List of MIPS Quality Measures?
Figure 1: Where to find the full list of MIPS 2020 Quality Measures.

#2 ̶ What Are Specialty Measure Sets and How Do They Categorize
MIPS Quality Measures?
Specialty measure sets categorize the 219
MIPS quality measures in 2020 by specialty.
Specialty measure sets include measures that
relate to a clinician’s expertise and regular
practice. Some specialty measure sets include
more measures than others (figure 2).

Figure 2: Measure count by specialty measure set.
Measure Count
20 40 60
20 40 60

Measures in a specialty measure set are
relevant, but not unique, to that specialty.
For example, the specialty set for
orthopedic surgery includes Measure 130:
Documentation of Current Medications in
the Medical Record. Measure 130 is
relevant, but not unique to orthopedic
surgery.

While specialty measure sets help you
find measures relevant to your specialty,
know that your best measure(s) may be
outside of your specialty measure set.
You are not limited to the measures in
your specialty set. And your highest
performance might be in a measure not
in your measure set.

#3 ̶ What Are Submission Methods for MIPS Quality Measures?
MIPS participants report MIPS quality
measures using submission methods.
MIPS offers four submission methods for
MIPS quality measures:
1. Claims
2. EHR
3. Registry
4. CMS Web Interface

No submission method can report all 219
MIPS quality measures. However, you
should know that some submission
methods offer more measures than others.
Registry submission can report the most
measures, often including 100 percent of
measures in a specialty measure set.
Here’s a comparison of measures counts
for each submission method (figure 3).

Figure 3: Measure count in each collection type.

You’ll find this same discrepancy in each
specialty measure set.
Your submission method may or may not
include all the specialty-specific measures
your physicians prefer.
Below is a snapshot of the discrepancy
across specialty measure sets (figure 4).

Measure count in each collection type (submission method)
in sample specialty measure sets.
Web Interface
Claims
EHR
Registry
Key
Figure 4: Measure count in each collection type.

Different submission methods offer
different measure counts for each
submission method.
For example, the gastroenterology
specialty measure set includes 15
total measures.
Within that set, EHR submission
includes five of 15 measures. And
registry submission includes all 15
measures–10 extra measures.

Gastroenterologists submitting through a
registry can report those extra measures.
However, gastroenterologists reporting with
an EHR cannot submit those 10 extra
measures.
Those extra registry measures are unique
to gastroenterology, making them preferable
to gastroenterologists in most cases.

The extra measures offered by registry
submission are normally specialty-specific
measures.
And that’s how submission methods may
include or exclude specialty-specific
measures your physicians prefer.

So, when selecting your MIPS quality
measures, pay attention to what
measures you can report through the
submission method you plan to use.
If the measures your physicians
would prefer are not available for
reporting through that submission
method, you should re-select your
submission method.

#4 ̶ How Are Denominators Calculated for MIPS Quality Measures?
Measure denominators identify the number of
patients eligible for a MIPS quality measure.
Measure specifications identify eligible patients
using age range, gender, diagnosis, treatment,
procedure, and other factors.
Broad criteria, like age, increase the number
of patients eligible for a measure. On the
other hand, narrow criteria, like low-volume
procedures, decrease the number of patients
eligible for a measure.

Figure 5: Calculating MIPS quality measures denominators.

Below are criteria examples, moving from broad to narrow:
Age
Measure 113
Percentage of
patients 50-75 years
of age who had
appropriate
screening for
colorectal cancer.
Age + gender
Measure 048
Percentage of female
patients aged 65
years and older who
were assessed for
the presence or
absence of urinary
incontinence within
12 months.
Age + date range
Measure 110
Percentage of
patients aged 6
months and older
seen for a visit
between October 1
and March 31 who
received an influenza
immunization or…
Age + Diagnosis
Measure 001
Percentage of
patients 18-75 years
of age with diabetes
who had hemoglobin
A1c > 9.0 percent
during the
measurement period.

Age + treatment
Measure 238
Percentage of
patients 65 years of
age and older who
were ordered high-
risk medications.
Age + finding
Measure 128
…AND with a BMI
outside of normal
parameters…
Procedure
Measure 145
Final reports for
procedures using
fluoroscopy that
document radiation
exposure indices,
or…
Age + procedure
Measure 044
Percentage of
isolated Coronary
Artery Bypass Graft
(CABG) surgeries for
patients aged 18
years and older
who…

Diagnosis + treatment
Measure 143
All patient visits,
regardless of patient
age, with a diagnosis
of cancer currently
receiving chemo-
therapy or radiation
therapy…
Event
Measure 046
The percentage of
discharges from any
inpatient facility (e.g.,
hospital, skilled
nursing facility, or
rehabilitation facility)
for patients 18 years
and older of age.
Biopsy
Measure 249
Percentage of
esophageal biopsy
reports that
document the
presence of Barrett’s
mucosa that also
include a statement
about dysplasia.”

#5 ̶ How Are Numerators Calculated for MIPS Quality Measures?
Numerators are calculated for MIPS quality
measures using the measure’s specifications.
The measure’s specifications define when it’s
too late to fulfill a measure (case unit) and
what data can be used to calculate each
measure (collection types).

What Are Case Units for MIPS Quality Measures?
In every quality measure, a measure
case has a particular unit.
These units include patients, periods,
episodes, encounters/visits, and
procedures.
These units also determine when it is
too late to complete a measure within
the performance period (figure 6).

UNIT DURATION EXAMPLE
Patient One case is equivalent to a
patient for the course of the
entire measurement period.
Quality# 226 - Tobacco Screening and Cessation Intervention expects a
patient to receive a screening and/or intervention once with in the
appropriate look back period of the measurement period.
Period One case is equivalent to a
patient over the course of a
sub-period within the
measurement period.
Quality# 110 - Influenza Immunization expects a patient to receive an
immunization during both the Jan-Mar and Oct-Dec flu seasons.
Episode One case is equivalent to one
episode of care a patient
receives.
Quality# 104 - Prostate Cancer: Adjuvant Hormonal Therapy expects a
patient to be prescribed hormonal therapy once for every 8-week episode of
radiation therapy.
Encounter/
Visit
One case is equivalent to
one office visit a patient has
with the provider.
Quality# 130 - Documentation of Current Medications expects medications to
be documented during every patient visit.
Procedure One case is equivalent to
one procedure a patient
receives from the provider.
Quality# 225 - Radiology: Reminder System for Screening Mammograms
expects the provider to document information into their reminder system
every time the patient receives a mammogram.
Figure 6: Case units for MIPS quality measures.

With patient-based measures, you’ll find an additional
caveat. You need to look at whether the numerator
event can be completed:
A. Anytime in the measurement period
B. Within some time frame relative to any encounter
C. At the most recent encounter or assessment

When selecting MIPS quality measures,
you’ll want to consider the unit for each
measure case in conjunction with the
benchmarks for the measure.
Some measure benchmarks have blank
deciles. In these measures, you can lose
between two and seven points if your
performance percentage drops from 100
to 99.99 percent.

You can recall patients and complete numerator
events in measures with patient and period units.
Doing so would bring your score back up to 100
percent and regain your two to seven points.
On the other hand, you can’t recall patients to
complete numerator events in measures with
episode, encounter, and procedure units.

What Are Collection Types for MIPS Quality Measures?
CMS defines collection types as “a set of
quality measures with comparable
specifications and data completeness criteria.”
The word “specifications” is key because
measure specifications dictate what data in
your PM or EHR can be used to calculate
measure results.
In that way, collection types dictate what
data can and cannot be used to calculate
your measure results.

You must carefully collect numerator data in
your PM or EHR where prescribed by your
collection type.
That’s because you can’t get credit for
qualifying numerator data you collect
outside of the data parameters dictated
by the collection type.

That’s true for every collection type except
for CQMs, the data collection for registry
submission.
Registry submissions can customize the
discrete data fields used for reporting.
If reporting with a registry, talk to your registry
representative about what data fields you use
to capture numerator data.

Each submission method has one collection
type. However, one quality measure may have
multiple collection types.
That’s because the same quality measure can
be reported by more than one submission
method. Figure 7 below that explains the hit-
and-miss reality across submission methods
(like the game of Battleship):

Figure 7: Collection types for MIPS quality measures.

If you use claims to report your quality
data, only data documented in claims will
report to CMS.
Similarly, if you use your EHR file to report
your data (the QRDA), only data
documented in your EHR’s mapped data
fields will be reported to CMS.

In the battleship example above, blue boxes
represent those data fields.
Data captured outside those mapped data
fields will not be reported to CMS. And that
decreases your performance.
Finally, registries like Able Health have the
option to use all discrete data fields in your
PM and EHR. However, be aware that not
all registries use all data fields.

As you would imagine, the use of different
data between submission methods (and
their corresponding collection types)
creates different performance results.
Consider this example comparing two
submission methods for the same
measure (figure 8):

Figure 8: Comparison of EHR versus Registry submission methods.

The comparison shows that registry submission
performs higher than EHR. The 90th percentile of
clinicians reporting this measure with an EHR
performed between 67.60 to 84.98 percent.
On the other hand, the 90th percentile of
clinicians reporting this measure with a registry
performed between 96.41 to 99.99 percent.
The difference is likely because registry
submissions can use more data when
calculating measure results.

Beyond scoring advantages, the registry collection
type represents a universal time savings.
That’s because the registry can adapt to the
physician’s documentation rather than the
physicians (or coders) adapting to reporting
requirements.

#6 ̶ Wow Are Benchmarks Used to Score Your Performance in MIPS
Quality Measures?
Benchmarks divide provider performance for
each measure into 10 parts. Those ten parts
are called deciles. Each decile represents the
performance for 10 percent of providers in a
previous year of MIPS.
The achievement points you earn for each
MIPS quality measure depends on where your
performance falls in a measure’s deciles.
Each decile number equals the number of
points your performance earns.

For example, a final performance falling into decile 8 earns between 8.0-8.9
performance points. A performance of 98 percent would land in decile 8 in
the example below (figure 9):
Quality Measures?
Figure 9: how benchmarks are used to score MIPS quality measure performance.

Quality Measures?
Different measures have different benchmarks. Some are very different.
Those differences create confusion, causing some
MIPS leaders to make two common mistakes when
reviewing measures and their benchmarks.
Mistake #1 Mistake #2
People think measures are
difficult when they are easy.
easy when they are difficult.

Quality Measures?
Many people believe high benchmarks reflect a
difficult measure. Consider this example (figure 10):
Mistake #1
Figure 10: Example of an easy measure based on benchmark data.

Quality Measures?
People believe these benchmarks reflect a difficult
measure. However, this is an easier measure and
the benchmarks prove it.
Each decile represents the actual performance of 10
percent of providers in previous years. With that in
mind, the benchmarks show that 70 percent of
clinicians finished at 100 percent in previous years
(deciles 4-10).
These benchmarks do not create a standard of
perfection; they reflect perfection for 70 percent of
providers who scored 100 percent.
Mistake #1

Quality Measures?
Many people believe low benchmarks reflect an easy
measure. Consider the next example (figure 11):
Mistake #2
Figure 11: Example showing a difficult measure based on benchmark data.

Quality Measures?
People believe these benchmarks reflect an easy
measure. However, this is a more difficult measure
and the benchmarks prove it.
Remember that each decile represents the actual
performance of 10 percent of providers in previous
years.
With that in mind, the benchmarks show that 70
percent of clinicians did not perform above 25
percent in a previous measurement period (up to
decile 7). These benchmarks show that 70 percent of
providers had difficulty with this measure.
Mistake #2

Quality Measures?
While you should review benchmarks when
selecting MIPS quality measures, you should
also know that you can’t gain a scoring
advantage by cherry picking measures based
on their benchmarks.
Benchmarks are set by past clinician
performance.

Quality Measures?
That means your performance is compared to
the performance of other clinicians, not an
arbitrary scoring standard.
That’s also true as it relates to one measure
with two collection types.
The two benchmarks were set by clinicians
reporting the measure with either the same
limitations and advantages.

#7 ̶ Other than Benchmarks, What Does CMS Use to Score Your
Performance in MIPS Quality Measures?
Beyond each measure’s benchmarks, CMS uses
many other factors to determine the achievement
and bonus points you earn for each measure.
The list of factors includes:
• The presence or absence of benchmarks
• A seven-point cap on topped-out measures
• A high-priority designation
• A bonus for end-to-end reporting
• Data completeness criteria
• Case minimums.

You can see some of these factors in the scoring example below (figure 12):
Figure 12: Factors determining MIPS quality measure performance.

How CMS Calculates Achievement Points for MIPS Quality Measures
Benchmarks No benchmarks Seven-point Cap
See above Some measures do not have historical
benchmarks. For that reason, CMS cannot
award measure achievement points as normal.
You could earn points as normal if the QPP can
reliably establish benchmarks using the current
performance period data. But as a worst case,
your qualifying submission for measures without
benchmarks earns three points. Approximately
30 percent of the 219 quality measures do not
have benchmarks. See Quality # 394 in the
example above.
CMS applies a scoring cap of seven points to
measures that have been topped out for two or
more consecutive years. The QPP considers a
measure topped out when historical
performance has been so high that meaningful
distinction between clinicians can no longer be
measured. You’ll find that approximately 20
percent of the 219 quality measures have a
seven-point cap. See Quality # 320 in the
example above.

How CMS Calculates Achievement Points for MIPS Quality Measures
Case Minimums Data Completeness
You earn a maximum of three points for
measures you report that include less than the
required cases (generally 20).
You earn one point for measures you report that
include less than the required data
completeness criteria (generally 70 percent).
However, if your group is a small practice, you
earn three points.

How CMS Calculates Bonus Points for MIPS Quality Measures
Reporting additional
high-priority measures
End-to-end measure reporting NOTE:
You earn two bonus points for
additional outcome or patient
experience measures you report.
Also, you earn one bonus point for
additional high-priority measures
that are not outcome measures.
The QPP caps these bonus points
at 10 percent of your quality
denominator. You do not earn bonus
points for the required outcome
measure (or high-priority measure if
no outcome measure is available).
You earn one bonus point for
measures you report directly from
2015 Certified EHR Technology
(CEHRT). You must report
measures without any manual
manipulation. The QPP caps end-to-
end bonus points at 10 percent of
your category denominator.
the QPP caps end-to-end bonus
points at 10 percent of your quality
category denominator. Similarly, the
QPP caps bonus points for
additional high-priority measures at
10 percent of your quality
denominator. Those are two
separate caps that combine for up
to a 20 percent bonus in the MIPS
quality category.

#8 ̶ What is the Burden of Different MIPS Quality Measures?
Some measures represent a significant
burden to your clinicians. On the other hand,
some measures add no additional burden.
Those measures simply quantify what is
already in place. When choosing MIPS
quality measures, consider the burden on
physicians to complete the measure.

Here are some examples of measures that
quantify clinical quality without adding a
burden to your clinicians:
Measures you’re already doing
Measures that quantify how much you
don’t do something
Structure measures
Outcome measures
>
>
>
>

Measures you’re already doing
Unrelated to MIPS, your clinical practice
might already follow practice guidelines
behind MIPS quality measures.
To state the obvious, quality measures
already apart of your regular practice require
no additional time to complete for MIPS.
If you’ve not found any overlap, make sure
you’re looking at the full list of MIPS quality
measures for 2020. Don’t limit yourself to the
47 measures tracked in an EHR.

Measures that quantify how much you don’t do something
Measures intended to eliminate or reduce an
activity require no additional time to complete.
One example is Quality # 238: Use of High-risk
Medications in the Elderly. Additionally, many
of the 19 measures in the Efficiency-and-Cost-
Reduction domain seek to curb overuse (stop
or reduce clinical activities).

Structure Measures
Automated with the right technology, some
structure measures require no additional time
to complete.
One example is Quality # 137: Melanoma:
Continuity of Care – Recall System. Another
example is Quality #225: Radiology: Reminder
System for Screening Mammograms.

Outcome Measures
Outcome measures, including
intermediate outcome measures, require
no additional time to complete.
That’s true if you’re already collecting the
necessary clinical values to quantify the
resulting state.
For example, if your patient intake
includes vitals, you can report for Quality
# 236: Controlling High Blood Pressure.

#9 ̶ What is the Documentation Burden of Different MIPS Quality Measures?
Documentation varies by measure and the
measure’s submission method. Some
measure documentation burdens your
clinical team and some doesn’t.
Consider the documentation differences
between measures and make sure your
team can keep up.
Documenting the measure is just as
important as doing the measure, because
like in medical billing, “if it wasn’t
documented, it wasn’t done.”

When choosing MIPS quality measures consider
the differences between measures and collection
types (submission methods).
Differences Between Measures
Differences Between Submission
Methods for the Same Measure
Some measures require clinicians to
document several data points. Other
measures don’t. Balance the
opportunity and the opportunity cost
of each measure.
Different submission methods use
different data fields for the same
measure. This question returns to an
image shown previously in this guide:

Figure 13: Collection types for MIPS quality measures.

The differences between submission methods creates a different level of
documentation burden for your clinicians.
Claims submission EHR submission Registry submission
You only earn credit for claims
submitted with quality data codes
like G-codes (e.g. G8420) or CPT II
codes (e.g. 3036F). These codes
quantify complex numerator events
with a single input, making data entry
as fast as possible.
You only earn credit for only your
EHR’s prescribed list of data fields
that they have mapped to nationally
recognized data standards like
SNOMED CT, MEDCIN, ICD-10-CM,
and LOINC. However, some of these
EHR workflows (mapping) burden
your clinicians unnecessarily. That
happens when EHR’s poorly map
user workflows to these elements.
Or, preferred workflow isn’t mapped.
You earn credit for any discrete data,
including the data fields not mapped
by your EHR. That includes, but is
not limited to, the claims and EHR
data fields above. That compre-
hensive use of your data results in
documentation flexibility for your
clinicians. They choose the workflow
that is the fastest and most efficient
for them.

#10 ̶ What is a Measure Steward for MIPS Quality Measures?
A measure steward is an organization
that owns and maintains a measure.
Pay attention to measure stewards
because physicians may be more
welcoming of quality measures
stewarded by organizations they value.
Able Health’s downloadable measure list
identifies measure stewards for each
MIPS quality measure (figure 14).

Quality
Number
NQS Domain
Measure
Type
Meaningful Measure Area
High-
Priority
Measure
Primary Measure
Steward
185
Communication and
Care Coordination
Process Appropriate use of healthcare X
American Gastroenterological
Association
187
Effective Clinical
Care
Process Medication Management - American Heart Association
191
Effective Clinical
Care
Outcome
Management of Chronic
Conditions
X
Physician Consortium for
Performance Improvement
192 Patient Safety Outcome
Conditions
X
Physician Consortium for
Performance Improvement
195
Effective Clinical
Care
Process Preventable Healthcare Harm -
American College of
Radiology
205
Effective Clinical
Care
Process
Conditions
-
National Committee for
Quality Assurance
Figure 14: Downloadable MIPS 2020 measure list.

Measure stewards of MIPS quality measures
are organizations like CMS, the National
Committee for Quality Assurance, the
National Quality Forum, and the American
Heart Association.
However, the list doesn’t stop there.
Many medical associations your physicians
belong to are also measure stewards.

#11 ̶ What Evidence Do Measure Stewards Use to
Create MIPS Quality Measures?
Measure specifications detail the purpose
of MIPS quality measures.
That merit is described in two sections:
Clinical Recommendation Statements and
Rationale.
Here is an example from Quality #046:
Medication Reconciliation Post-Discharge:

#11 ̶ What Evidence Do Measure Stewards Use to
Create MIPS Quality Measures?
The research and statistics in these sections
empower you to qualify and quantify clinical value.
For example, let’s say 1,000 of your patients are
discharged monthly from an inpatient setting.
Let’s also say that 60 percent of those discharges
were elderly patients.
The study referenced in Quality #46 suggests
that 432 of those 1,000 patients would be “taking
incorrectly at least one medication started in the
inpatient setting.”

#12 ̶ What Are the Types of MIPS Quality Measures?
MIPS quality measures fall into seven different
types. The type of measure matters for various
big-picture reasons.
First, outcome measures, including intermediate
and patient-reported outcome measures, earn two
bonus points. Second, process measures are more
prone to be removed from MIPS in future years.
Third, efficiency measures can help you perform
better in the cost category and prepare for shared-
savings and bundled-payment programs.
Finally, some structure measures can be automated.

Figure 15: The seven types of MIPS quality measures.

Process Measures Outcome Measures
Intermediate outcome
measures
Patient-reported
outcome measures
Quantification of clinical
activities performed for the
patient or by the patient. An
example is Measure 112:
Breast Cancer Screening.
A resulting health state of a
patient reported by the
clinician. An example is
Measure 398: Optimal Asthma
Control.
A short-term resulting health
state of a patient, that
contributes to a long-term
state, reported by the clinician.
An example is Measure 236:
Controlling High BP.
A resulting health state of a
patient reported by the patient.
An example is Measure 375:
Functional Status Assessment
for Total Knee Replacement.
Efficiency measures Structure measures
Patient-engagement and
patient-engagement
measures
Appropriate use of clinical
activities under specific
circumstances. An example is
Measure 439: Age Appropriate
Screening Colonoscopy.
A healthcare delivery feature
enabling high-quality care. An
Radiology: Reminder System
for Screening Mammograms.
Feedback from patients about
the experience of care. An
Patient Satisfaction within 90
Days Following Cataract
Surgery.

What to do next
Make sure your list of MIPS quality
measures is the very best selection for
your team.
You may want to replace one or more
measures on your list using the
measure-selection tips in this guide.
And if you’re new to MIPS, follow these
12 FAQs sequentially in order to identify
the best measures for your team.

For more information:
“This book is a fantastic piece of work”
– Robert Lindeman MD, FAAP, Chief Physician Quality Officer

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Rachel Katz

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Darren O’Brien

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