How to Collect Data for the Quality Performance Category

Collection Type” refers to the method used in gathering data for a MIPS quality measure. Although one quality measure can be collected via different methods, each has unique reporting instructions. You should follow the specifications that align with your chosen data collection method.  

To ensure that you meet data completeness requirements, you should have started collecting data on January 1st, 2023. If you fail to meet these requirements, you will receive 0 points for the measure (or 3 points if you are a small practice). For your data to be “complete” you must report performance data for at least 70% of the eligible population. The “eligible population” can change depending on the type of measure you are reporting: 

  • For Medicare Part B claims measures, CMS identifies the eligible denominator patient population based on your submitted Medicare Part B claims.  
  • For eCQMs, MIPS Clinical Quality Measures (MIPS CQMs), and QCDR measures, you identify the eligible population in your submission according to the Quality Reporting Document Architecture (QRDA) III or QPP JavaScript Object Notation (JSON) specifications. 

Electronic Clinical Quality Measures (eCQMs): You can report electronic Clinical Quality Measures (eCQMs) if you’re using an EHR that is certified by the Office of the National Coordinator for Health Information Technology (ONC) with a 2015 Edition Cures Update CEHRT. This certification needs to be in place when you generate eCQM data for submission. Be sure your tech is up to date to collect the latest measure specs. If you use multiple EHRs you’ll need to aggregate your data before it’s submitted.

MIPS Clinical Quality Measures (MIPS CQMs): MIPS CQMs are often collected by third party intermediaries and submitted on behalf of MIPS eligible clinicians. If you chose this collection type, you may choose to work with a QCDR, Qualified Registry, or Health IT vendor to support your data collection and submission, or you can submit them yourself. To see the lists of CMS-approved QCDRs and Qualified Registries, visit the QPP Resource Library

Qualified Clinical Data Registry (QCDR) Measures: QCDRs are CMS approved entities that have the flexibility to develop and track their own quality measures which are approved during their self-nomination period. These measures can be a great option for clinicians and practices that provide specialized care or who have trouble finding MIPS quality measures that are relevant to their practice. You’ll need to work with the QCDR to report these measures on your behalf. 

Medicare Part B Claims Measures: Medicare Part B claims measures can only be reported by solo practitioners and small practices (15 or fewer clinicians). Individual clinicians reporting Medicare Part B claims measures should include their National Provider Identifier (NPI) and Taxpayer Identification Number (TIN), even when participating as a group, virtual group, or APM Entity. 

CAHPS for MIPS Survey Measure: Groups, virtual groups and APM Entities can register between April 3, 2023, and June 30, 2023, to administer the CAHPS for MIPS Survey measure, a survey measuring patient experience and care within a group, virtual group or APM Entity. This survey must be administered by a CMS-Approved Survey Vendor. 

If you don’t have 6 suitable measures, or a significant outcome/high priority measure to report, try taking a look at the specialty measure sets. You can meet the reporting requirements by completing a specialty set, even with less than 6 measures. 

If a specialty set is not totally relevant to your scope of practice, report all measures that do clinically apply. CMS will use the Eligible Measure Applicability (EMA) process to review your data and see if there were more measures you could have reported. 

The EMA process, which can lead to a reduction in total measures for those who reported all relevant measures, applies to all MIPS-eligible clinicians and entities that have reported Medicare Part B claims measures or MIPS CQMs. 

All information, documents, and resources pertaining to these quality measures can be found on the QPP Resource Library

TIP: To review the 2023 MIPS Quality Measures, visit the Explore Measures & Activities section of the Quality Payment Program website and choose the 2023 performance period. You can also find the Quality Measure specifications zip file posted by collection type on the QPP Resource Library