How using the MIPS 90-day reporting period will increase your 2017 Composite Score

One helpful feature of the 2017 “transition year” for the Merit-based Incentive Payment System (MIPS) is the option to report quality data for a minimum of 90 days. In 2017 (and 2017 only!) you can earn full credit in the MIPS Quality category with only 90 days worth of data. If you are not already planning to exercise this option, you may want to consider it: 90-day reporting is virtually guaranteed to increase your MIPS Composite Performance Score! Read on to find out why.

By instituting the 90-day reporting option, the Centers for Medicare and Medicaid Services (CMS) aimed to assist eligible clinicians and groups by requiring less documentation and data analysis during the 2017 transition year. But even if you have been documenting data for MIPS all year, exercising this option will allow you to retroactively identify your best reporting period and increase your Composite Performance Score with the data you already have.

Able Health has worked with CMS to understand exactly how CMS expects providers to calculate measure performance for 90-day reporting periods using the registry or QCDR submission mechanisms. Below you can find our distilled guidelines, which we have also automated into the Able Health Qualified Clinical Data Registry (QCDR) measures engine for our customers.

How 90-day reporting works

The first thing to note about calculating measure performance for 90-day reporting periods is that only certain records (primarily in the denominator) are constrained to your 90-day period. Other records (primarily in the numerator) can still be documented any time during the 2017 performance year. Note that this is specific to reporting using the registry and QCDR submission mechanisms, and you should verify this guidance if reporting using other submission mechanisms.

The following table breaks down the two date ranges to consider, which we call the Performance Year and the Reporting Period:

 

Performance Year Reporting Period (e.g. 90 days)
  • Jan 1, 2017 – Dec 31, 2017
  • Patients can meet numerator quality action criteria any time during this period
  • Also applies to denominator exceptions and certain denominator criteria on a measure-by-measure basis
  • Your selected 90-365 day window within the performance year
  • Patients can meet (most) denominator eligibility criteria any time during this period
  • Also applies to denominator exclusion criteria

 

Note that both of these date ranges may be further modified within the specification of each particular measure

What this means for your Composite Score

To maximize your composite performance score, you will need to identify the 90-day period where you encountered patients who met the numerator at any point in 2017. This can be a difficult optimization to perform manually, but can be easily performed using a tool like Able Health’s MIPS Dashboard.

Example Calculations

Below you can find examples of how to calculate measures using a 90-day performance period. The tables indicate how the date ranges for specific clinical records in the measure specification would or would not be modified. This does not include an exhaustive list of records used in each measure.

For a standard example, we will review Measure 048: Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older. This measure follows the rule that denominator data is constrained to the reporting period, while the numerator quality actions can be achieved anytime during the performance year. This model can be applied as a template to many measures.

 

Reporting Criterion Original Measure Requirements Modified Date Range
Denominator Encounter during performance year Encounter must be within the 90-day reporting period
Denominator Exclusion Hospice Service during performance year Hospice must be within the 90-day reporting period
Performance Met Assessment for Urinary Incontinence during performance year Assessment may be anytime within the 2017 performance year

 

Of course, there are exceptions to every rule. There are some measures that stipulate a specific time period in which records need to be documented. One example is Measure 110: Preventative Care and Screening: Influenza Immunization. To meet the performance you must have an visit and an immunization during flu season (October-March). If you choose a reporting period that does not include these months, this measure would have no patients in the denominator and should not be reported.

 

Reporting Criterion Original Measure Requirements Modified Date Range
Denominator 1-2 encounters during flu season Encounters must be within 90-day Reporting Period AND flu season
Denominator Exclusion Allergy or intolerance to influenza immunization active during flu season Allergy active during 90-day Reporting Period AND flu season
Performance Met Influenza immunization during flu season Immunization during flu season

 

Another example that works a bit differently is Measure 447: Chlamydia Screening and Follow Up. This denominator for this measure requires an encounter in to occur in the selected 90-day period for 2017, but also requires at least one encounter in the previous year.

 

Reporting Criterion Original Measure Requirements Modified Date Range
Denominator (part 1) Encounter during performance year Encounter must be within the 90-day reporting period
Denominator (part 2) Encounter during prior year Encounter must be in 2016 Performance Year
Performance Met Chlamydia screening during performance year Screening may be anytime within 2017 Performance Year

 

Measures not to report during 90-day periods

Below you can find a table of measures with reduced or zero denominators if reported during certain months. This is because the original measure specification limits reporting to specific months of the year—for example, flu season for the Influenza Immunization. This is not an exhaustive list, so check any date range restrictions indicated in each measure specification.

 

Measure Months Excluded from Reporting
110: Preventive Care and Screening: Influenza Immunization April – September
191: Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery October – December
303: Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery October – December
304: Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery October – December
355: Unplanned Reoperation within the 30 Day Postoperative Period December
356: Unplanned Hospital Readmission within 30 Days of Principal Procedure December
389: Difference Between Planned and Final Refraction October – December
408: Opioid Therapy Follow-up Evaluation October – December

 

Finding your best period

Participating in MIPS using a 90-day reporting period is one of the simplest ways to increase your Composite Performance Score in 2017—if you have the tools to support this. Request a demo of how our dashboard enables you to perform this analysis based on the patient data you already have in your Electronic Health Record or billing system.

Stay up to date on the evolving Quality Payment Program and other quality reporting requirements by signing up for the Able Health newsletter!


Further reading:
Avoiding a penalty in 2018 MIPS: the nuts and bolts
Radiology & MIPS Reporting: Everything You Need to Know

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