How to Effectively Submit Data in the Quality Performance Category 

Once the 2023 Performance Year (PY) has concluded on December 31, 2023, CMS will assess your performance in the Quality Performance Category based on the quality measure data you submit during the data submission period. The PY 2023 data submission period will open on January 2, 2024, and close on April 1, 2024.

There are 5 ways you can collect and submit your quality measures data to CMS: Electronic Clinical Quality Measures (eCQMs), MIPS Clinical Quality Measures (MIPS CQMs), Qualified Clinical Data Registry (QCDR) Measures, Medicare Part B Claims Measures, and the CAHPS for MIPS Survey Measure. 

The following charts outline your options for submitting quality measure data based on your submission and collection types: 

Submitter Type: You (Individual, Group, Virtual Group, or APM Entity Representative)  

What (Collection Type) How (Submission Type) When (Submission Period) 
Medicare Part B Claims (small practices only) Through your routine Medicare Part B claims billing practices Throughout the performance period (must be processed by your MAC and received by CMS by March 1, 2024)  
eCQMs Sign in to the Quality Payment Program website and upload a QRDA III file or a QPP JSON file.  January 2 – April 1, 2024   
MIPS CQMs Sign in to the Quality Payment Program website and upload a QPP JSON file.  January 2 – April 1, 2024   

Submitter Type: Third Party Intermediaries: QCDRs, Qualified Registries, and Health Information Technology (IT) Vendors: 

What (Collection Type) How (Submission Type) When (Submission Period) 
eQCMs, MIPS QCMs, QCDR Measures Sign in to the Quality Payment Program website and upload a QRDA III or QPP JSON file  OR Use the QPP Submission Application Programming Interface (API). January 2 – April 1, 2024   

Submitter Type: CMS-Approved Survey Vendors 

What (Collection Type) How (Submission Type) When (Submission Period) 
CAHPS for MIPS Survey Measure   
Secure method outside of the Quality Payment Program website.  Following data collection (standardized annual timeframe) 

For Medicare Part B Claims measures (available for small practices only) CMS gets quality data when you submit claims that are eligible and contain quality data codes (QDCs) from your chosen quality measures. Remember, your Medicare Part B claims data needs to be processed by your Medicare Administrative Contractor (MAC) and sent to CMS within 60 days after the end of the 2023 performance period. 

For practices submitting eCQMs, if you switch Electronic Health Record (EHR) systems during the year, or use multiple EHRs, you’ll need to merge data from all of the EHR systems into a single 12-month report. If you can’t combine data for the full year, submit as much as you can, but the 12-month, 70% completeness rules still apply. For the 2023 performance period, the submitting EHR systems used must all have the 2015 Edition Cures Update certification before the eCQM data is generated.

Did you know?

Generally, the level at which you participate in MIPS (individual, group, or virtual group) applies to all MIPS performance categories. CMS won’t combine data submitted at the individual, group, and/or virtual group level into a single MIPS final score.

This means: 

  • If you submit any data as an individual, you’ll be evaluated for all performance categories as an individual.  
  • If your practice submits any data as a group, you’ll be evaluated for all MIPS performance categories as a group.  
  • If data is submitted both as an individual and a group, you’ll be evaluated as an individual and as a group for all MIPS performance categories, but your MIPS payment adjustment will be based on the higher score.

If you’d like to know more about submitting MIPS Quality data, you can visit the CMS website or reach out to your HCIS MIPS advisor.