The traditional Merit-based Incentive Payment System (MIPS) is the original reporting option available to MIPS eligible clinicians for collecting and reporting data to MIPS. The quality performance category evaluates the quality of care you deliver by measuring health care processes, outcomes, and patient experiences of care. Note: requirements may change each performance year due to policy changes.
What Quality Data Should I Submit
Providers must collect and submit measure data for the current 12-month performance period (January 1 - December 31). There are 5 collection types for MIPS quality measures:
- Electronic Clinical Quality Measures (eCQMs)
- MIPS Clinical Quality Measures (CQMs)
- Qualified Clinical Data Registry (QCDR) Measures
- Medicare Part B Claims Measures
- The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Survey
Keep in Mind:
- Providers must submit data for at least six quality measures (including one outcome measure or high priority measure in the absence of an applicable outcome measure), or a complete specialty measure set.
- Providers have to report data for at least 75% of eligible cases for each quality measure.
- Providers can use different collection methods to report data for at least six quality measures.
- If applicable and if requirements are met, 4 administrative claims measures for individuals, groups, virtual groups, and APM Entities will be automatically calculated and scored.
Electronic Clinical Quality Measures (eCQMs)
A clinical quality measure that is captured in certified electronic health record technology (CEHRT). Data is collected in a structured, consistent format during the process of patient care.
MIPS Clinical Quality Measures (CQMs)
Tools that help us measure or quantify health care processes, outcomes, and patient perceptions that are associated with the ability to provide high-quality healthcare.
Qualified Clinical Data Registry (QCDR) Measures
A QCDR measure is a registry specific metric created to fulfill group, ED, and individual quality outcomes.
CAHPS for MIPS Survey
If providers register for the CAHPS for MIPS Survey and meet the requirements, this measure can count as one of the six necessary quality measures. Note: starting in 2024, providers are now required to use a CAHPS for MIPS Survey vendor to provide the survey in Spanish to Spanish-speaking patients.
Administrative Claims Measures
If applicable and if requirements are met, the following administrative claims measures will automatically be calculated and scored:
- Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-based Incentive Payment System (MIPS) Eligible Groups. (This measure is only applicable to groups and virtual groups)
- Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) for Merit-based Incentive Payment System (MIPS)
- Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions
- Risk-Standardized Acute Unplanned Cardiovascular-Related Admission Rates for Patients with Heart Failure under MIPS
Specialty Measure Sets
If providers choose to submit data for a specialty measure set, they must provide data on at least six quality measures within that set.
For more detailed information regarding quality data within the Quality Payment Program, please visit the MIPS Requirements section of the QPP website: https://qpp.cms.gov/mips/quality-requirements
Or feel free to review the MIPS 2024 Quality Performance Category Guide below:
MIPS 2024 Quality Performance Category Guide