If you are reporting MIPS quality data through traditional MIPS or MIPS Value Pathways (MVPs), it’s crucial that you’re aware of the various data collection types available to you. Each collection type has its own process of being reported, and some measures are available under multiple collection types. The following will take you through each collection type, how they might differ from one another, and which type may fit best with your practice.
Electronic Clinical Quality Measures (eCQMs)
eCQMs are “measures specified in a standard electronic format using data electronically extracted from electronic health records (EHRs) and/or health information technology (IT) systems to measure the quality of health care provided.” They use clinical data to assess outcomes, reduce the burden of manual abstraction, and give access to real-time data for quality improvement.
You can report eCQMs if you use technology that meets the Certified Electronic Health Record Technology (CEHRT) certification from the Office of the National Coordinator for Health Information Technology (ONC) by the time eCQM data is generated for submission. To see if your HealthIT product meets CEHRT requirements, check out the Certified HealthIT Product List.
MIPS Clinical Quality Measures (MIPS CQMs)
Just like eCQMs, MIPS CQMs are collected from a valid data source, including EHR data. However, MIPS CQMs are often collected by certified third parties, such as MIPS Qualified Registries like Healthcare Innovation Solutions (HCIS). HCIS can assist you with MIPS reporting, submitting, and offers consulting services for all your MIPS needs.
Read about ‘2024 Clinical Quality Measure Specifications and Supporting Documents here.
Qualified Clinical Data Registry (QCDR) Measures
These measures can only be reported by working with a QCDR, which is a Centers for Medicare & Medicaid approved vendor including “specialty societies, regional health collaboratives, large health systems or software vendors working in collaboration with one of these medical entities.” According to CMS, “these measures can be a great option for clinicians and practices that provide specialized care or who have trouble finding MIPS quality measures that feel relevant to their practice.”
Read the 2024 QCDR Measure Specifications here.
Medicare Part B Claims Measures
These measures are only available to clinicians who are part of small practices (meaning any practice with 15 or fewer clinicians). Unlike other collection types, Medicare Part B Claims Measures are reported with the individual clinician’s National Provider Identifier (NPI) even when reporting as a group, subgroup, or virtual group.
View 2024 Medicare Part B Claims Measures Specifications and Supporting Documents here.
CAHPS for MIPS Survey Measures
The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Survey is an optional quality measure that groups and virtual groups participating in the Merit-based Incentive Payment System (MIPS) can choose to conduct. To participate, groups, virtual groups (for traditional MIPS reporting only), subgroups (for MVP reporting only), and APM Entities must register between April 1, 2024, and July 1, 2024. This survey evaluates the patient experience of those receiving primary care services and is particularly relevant for providers in that field. It is essential to administer this survey through a CMS-approved survey vendor.
Resources
HCIS has all your MIPS reporting and submission needs covered for the 2023 and 2024 Performance Years. To learn more about our services, please check out MIPS Pricing & Services.
The HCIS blog as all sorts of tips and updates regarding MIPS: