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Quality
Quality Reporting Requirements

For the 2022 Performance Year (PY), Providers can select from more than 200 available quality measures. Data needs to be collected and submitted for each quality measure for the entire 2022 calendar year.

To meet the Quality performance category requirements, a MIPS eligible provider, group, or virtual group can report:

  • 6 quality measures (including at least one outcome measure or high priority measure in absence of an applicable outcome measure) for the 12-month performance period; OR
  • A defined specialty measure set (if the measure set has fewer than 6 measures, all measures within that set need to be submitted); OR
  • All quality measures included in the CMS Web Interface, a collection type available to registered groups or virtual groups with 25 or more eligible providers.

Data Completeness

For 2022, the data completeness requirement is 70%. Providers need to report performance or exclusion/exception data for at least 70% of patients or encounters that are eligible for the measure’s denominator.

What’s New with Quality in 2022?

  • The quality performance category weight decreased from 40% to 30% for individual MIPS eligible providers, groups, and virtual groups participating in traditional MIPS.
  • Beginning with PY 2022, there are no bonus points for reporting additional outcome and high priority measures, or end-to-end electronic reporting.
  • CMS is extending the CMS Web Interface as a collection type and submission type in traditional MIPS for registered groups, virtual groups and APM Entities with 25 or more clinicians for the 2022 performance year.
  • Proposal to expand the list of reasons that a quality measure may be impacted to include errors included in the measure specifications as finalized as cause to suppress or truncate a measure. These errors include, but are not limited to:
    • Changes to the active status of codes.
    • The inadvertent omission of codes.
    • The inclusion of inactive or inaccurate codes
PI Reporting

PI Reporting Requirements

What’s New with Promoting Interoperability (PI) in 2022?

CMS proposed to apply automatic reweighting to the following, beginning with the 2022 performance period:
• Clinical social workers
• Small practices
• No reweighting for certified nurse midwives.

A new measure is proposed where MIPS eligible clinicians must attest yes/ no to conducting an annual assessment of the High Priority Guide of the Safety Assurance Factors for EHR Resilience Guides (SAFER Guides).

4th exclusion added to Electronic Case Reporting for PY 2022 only: Uses certified electronic health record technology (CEHRT) that isn’t certified to the electronic case reporting certification criterion at 45 CFR170.315(f)(5) prior to the start of the performance period they select in CY 2022.

CMS modified the reporting requirements for Public Health and Clinical Data Exchange objective and require MIPS eligible clinicians to report the following 2 measures (unless an exclusion can be claimed): Immunization Registry Reporting, Electronic Case Reporting

IA Reporting

IA Reporting Requirements

The Improvement Activities (IA) performance category focuses on one of the MIPS strategic goals, to use a patient-centered approach to program development that leads to better, smarter, and healthier care.

Improvement Activities are classified into Care coordination, Beneficiary engagement, and Patient safety sub-categories which MIPS eligible providers could select from a list of approximately 106 activities.

MIPS eligible providers or groups can attest to the activities performed for a period of minimum 90 continuous days and qualify for a score in IA category.

At least 50% of the providers (in the group or virtual group) must perform the same activity during any continuous 90-day period, or as specified in the activity description, within the same performance period.

What’s New with Improvement Activities (IA) in 2021?

  • Removal of Activities: In the case of an IA for which there is a reason to believe that the continued collection raises possible patient safety concerns or is obsolete, CMS would promptly suspend the improvement activity and immediately notify clinicians and the public through the usual communication channels.
  • Addition of 7 new IAs, 3 of which are related to promoting health equity.
  • Modification of 15 current IAs, 11 of which address health equity.
  • Removal of 6 previously adopted improvement activities.
cost Reporting

Cost Reporting Requirements

For the 2022 PY, the Cost category is included in the final score and is weighted for 15% of the final score. Cost will be calculated directly by CMS and therefore no submission will be required.

  • Reporting period will be for the full PY in 2022.
  • Individual eligible providers or groups will be scored on 25 measures included in the Cost performance category.
  • Medicare Spending per Beneficiary (MSPB), Total per Capita Cost measure for all attributed beneficiaries (TPCC) and 23 episode-based cost measures.
  • CMS will calculate Cost category score based on administrative claims data.

What’s New with Cost in 2022?

  • In addition to the current process, CMS is proposing a process of external cost measure development and a call for cost measures beginning in CY2022 for earliest adoption into the MIPS program by the 2024 performance period.
  • MIPS eligible providers in MIPS APMs who report to traditional MIPS as individuals, groups, or virtual groups will be scored on cost. However, eligible providers in a MIPS APM that reports to traditional MIPS as a MIPS APM Entity will not be scored on cost?

Reweighting of Performance Categories

For 2022 MIPS PY, CMS has finalized redistribution of the performance category weights.

Reweighting ScenarioQualityCost

Improvement

Activities

Promoting Interoperability
No Reweighting Needed
• Scores for all four performance categories30%30%15%25%
Reweight One Performance Category
• No Cost55%0%15%30%
• No Promoting Interoperability55%30%15%0%
• No Quality0%30%15%55%
• No Improvement Activities45%30%0%25%
Reweight Two Performance Categories
• No Cost and no Promoting Interoperability85%0%15%0%
• No Cost and no quality0%0%15%85%
• No Cost and no Improvement Activities70%0%0%30%
• No Promoting Interoperability and no Quality0%50%50%0%
• No Promoting Interoperability and no Improvement Activity70%30%0%0%
• No Quality and no Improvement Activity0%30%0%70%

CMS would apply automatic reweighting to the following, beginning with the 2022 performance period:
• Clinical social workers
• Small practices
• No reweighting for certified nurse midwives.