What’s a benchmark?
Unlike advancing care information and improvement activities, the quality category of MIPS is determining your performance by comparing it to a national benchmark. In other words, CMS wants to know how you stack up against everyone else in the country who reported on the same measure.
In order to create benchmarks for each measure, CMS will take information that was reported via PQRS 2 years prior to the current performance year. For CAHPS, benchmarks are set based on 2 surveys: 2015 CAHPS for PQRS and CAHPS for ACOs.
Submissions via CMS Web Interface will use benchmarks from the Medicare Shared Savings Program. CMS will then convert each measure into a 10-point scoring system. Each measure will be broken down into 10 “deciles,” with each decile reflecting one to 10 points. The deciles will be based upon stratified levels of national performance within that baseline period.
CMS QUALITY BENCH MARK DATA CLICK BELOW TO SEE THE FILE
Estimating your Quality Score
Although you probably won’t be able to pinpoint the exact score you will receive for quality (prior to submitting your data), you may be able to get within a close range.
Before we get started, let’s make the following assumptions in order to keep things as uncomplicated as possible:
- You are not a part of an APM
- Clinicians in an APM (and not in the advanced APM track of the quality payment program) will have their quality score measured in different ways (depending on their APM).
- You are not in a group of 16 or more clinicians
- Clinicians in a group size of 16 or more will also be measured up against the “all-cause hospital readmission” administrative claims measure.
Step 1: To estimate your quality score, you will first have to know your performance scores for each of the six measures you selected for either a 90-day reporting period or a full year.
Step 2: Open the benchmark spreadsheet provided by CMS. On the spreadsheet, you will need to locate the measure you are reporting AND the submission type you will be choosing (EHR, QCDR/Registry/Claims).
Step 3: Look for the decile that your percentage score fell into and the number of points assigned to that decile.
Step 4: Add up all your decile points for each of the measures you are reporting.
Step 5: Add up any bonus points you may have earned. Bonus points can be earned in many different ways (included the submission type you selected and if the measure is considered high priority or an outcomes measure).
Step 6: Take the total number of points you earned and divide it by 60.
There you have it! An estimated quality score!
Bad score? Don’t fret!
Since the measure benchmark scoring concept is new, CMS finalized a measure score “floor” of three points for the 2017 performance year. That means if you just submit “something” for one measure you will earn no less than 3 points (which is enough to avoid a MIPS penalty in 2019).
Also, because this year is a transition year (and the hurdle is set so low), you don’t have to scramble to find the “right” answer immediately. Take this year to learn about all the measures that may make sense for you to report and which submission method to choose. Although some measures may look appetizing, you may not perform so well compared to others across the nation.
Quality Measures
Instructions:
Review and select measures that best fit your practice.
“Add up to six measures from the list below, including one outcome measure”. You can use the search and filters to help find the measures that meet your needs or specialty.
If an outcome measure is not available that is applicable to your specialty or practice, chose another high priority measure.
Download a CSV file of the measures you have selected for your records.
DETAIL:
SUMMARY
Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use Acute Otitis Externa (AOE): Topical Therapy ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication Adherence to Antipsychotic Medications For Individuals with Schizophrenia Adult Kidney Disease: Blood Pressure Management Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days Adult Kidney Disease: Referral to Hospice Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions Adult Major Depressive Disorder (MDD): Suicide Risk Assessment Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse) Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use) Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse) Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse) Age Appropriate Screening Colonoscopy Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement Age-Related Macular Degeneration (AMD): Dilated Macular Examination All-cause Hospital Readmission Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences Anastomotic Leak Intervention Anesthesiology Smoking Abstinence Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users Anti-Depressant Medication Management Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal Appropriate Follow-up Imaging for Incidental Abdominal Lesions Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients Appropriate Testing for Children with Pharyngitis Appropriate Treatment for Children with Upper Respiratory Infection (URI) Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia Appropriate Workup Prior to Endometrial Ablation Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis Barrett’s Esophagus Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma: Biopsy Reporting Time – Pathologist to Clinician Biopsy Follow-Up Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade Breast Cancer Screening CAHPS for MIPS Clinician/Group Survey Cardiac Rehabilitation Patient Referral from an Outpatient Setting Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI) Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients Care Plan Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy) Cataract Surgery: Difference Between Planned and Final Refraction Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery Cervical Cancer Screening Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment Childhood Immunization Status Children Who Have Dental Decay or Cavities Chlamydia Screening and Follow Up Chlamydia Screening for Women Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation Clinical Outcome Post Endovascular Stroke Treatment Closing the Referral Loop: Receipt of Specialist Report Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade Colorectal Cancer Screening Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older Controlling High Blood Pressure Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery Coronary Artery Bypass Graft (CABG): Prolonged Intubation Coronary Artery Bypass Graft (CABG): Stroke Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy – Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%) Coronary Artery Disease (CAD): Antiplatelet Therapy Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%) Dementia: Caregiver Education and Support Dementia: Cognitive Assessment Dementia: Counseling Regarding Safety Concerns Dementia: Functional Status Assessment Dementia: Management of Neuropsychiatric Symptoms Dementia: Neuropsychiatric Symptom Assessment Depression Remission at Six Months Depression Remission at Twelve Months Depression Utilization of the PHQ-9 Tool Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear Diabetes: Eye Exam Diabetes: Foot Exam Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) Diabetes: Medical Attention for Nephropathy Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy Documentation of Current Medications in the Medical Record Documentation of Signed Opioid Treatment Agreement Door to Puncture Time for Endovascular Stroke Treatment Elder Maltreatment Screen and Follow-Up Plan Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy Evaluation or Interview for Risk of Opioid Misuse Falls: Plan of Care Falls: Risk Assessment Falls: Screening for Future Fall Risk Follow-Up After Hospitalization for Mental Illness (FUH) Functional Outcome Assessment Functional Status Assessment for Total Hip Replacement Functional Status Assessment for Total Knee Replacement Functional Status Assessments for Congestive Heart Failure Functional Status Change for Patients with Elbow, Wrist or Hand Impairments Functional Status Change for Patients with Foot or Ankle Impairments Functional Status Change for Patients with General Orthopaedic Impairments Functional Status Change for Patients with Hip Impairments Functional Status Change for Patients with Knee Impairments Functional Status Change for Patients with Lumbar Impairments Functional Status Change for Patients with Shoulder Impairments Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry Hematology: Multiple Myeloma: Treatment with Bisphosphonates Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2-Targeted Therapies HIV Medical Visit Frequency HIV Viral Load Suppression HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision Hypertension: Improvement in Blood Pressure Image Confirmation of Successful Excision of Image-Localized Breast Lesion Immunizations for Adolescents Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury – Bone Loss Assessment Initiation and Engagement of Alcohol and Other Drug Dependence Treatment Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control) Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet KRAS Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy Lung Cancer Reporting (Biopsy/Cytology Specimens) Lung Cancer Reporting (Resection Specimens) Maternal Depression Screening Maternity Care: Elective Delivery or Early Induction Without Medical Indication at >= 37 and < 39 Weeks (Overuse) Maternity Care: Post-Partum Follow-Up and Care Coordination Medication Management for People with Asthma Medication Reconciliation Post-Discharge Melanoma Reporting Melanoma: Continuity of Care – Recall System Melanoma: Coordination of Care Melanoma: Overutilization of Imaging Studies in Melanoma Non-Recommended Cervical Cancer Screening in Adolescent Females Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy Oncology: Medical and Radiation – Pain Intensity Quantified Oncology: Medical and Radiation – Plan of Care for Pain Oncology: Radiation Dose Limits to Normal Tissues One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk Operative Mortality Stratified by the Five STS-EACTS Mortality Categories Opioid Therapy Follow-up Evaluation Optimal Asthma Control Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison Purposes Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Studies Through a Secure, Authorized, Media-Free, Shared Archive Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging Description Osteoarthritis (OA): Function and Pain Assessment Osteoporosis Management in Women Who Had a Fracture Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination Pain Assessment and Follow-Up Pain Brought Under Control Within 48 Hours Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment Parkinson’s Disease: Parkinson’s Disease Medical and Surgical Treatment Options Reviewed Parkinson’s Disease: Psychiatric Symptoms Assessment for Patients with Parkinson’s Disease Parkinson’s Disease: Rehabilitative Therapy Options Patient-Centered Surgical Risk Assessment and Communication Patients with Metastatic Colorectal Cancer and KRAS Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies Pediatric Kidney Disease: Adequacy of Volume Management Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 10 g/dL Pelvic Organ Prolapse: Preoperative Assessment of Occult Stress Urinary Incontinence Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury Perioperative Anti-platelet Therapy for Patients Undergoing Carotid Endarterectomy Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) Perioperative Temperature Management Persistence of Beta-Blocker Treatment After a Heart Attack Photodocumentation of Cecal Intubation Pneumococcal Vaccination Status for Older Adults Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU) Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU) Pregnant women that had HBsAg testing Preoperative Diagnosis of Breast Cancer Prevention of Central Venous Catheter (CVC) – Related Bloodstream Infections Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan Preventive Care and Screening: Influenza Immunization Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care Proportion Admitted to Hospice for less than 3 days Proportion Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life Proportion Not Admitted To Hospice Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair Proportion of Patients Sustaining a Ureter Injury at the Time of any Pelvic Organ Prolapse Repair Proportion of Patients who Died from Cancer with more than One Emergency Department Visit in the Last 30 Days of Life Proportion Receiving Chemotherapy in the Last 14 Days of Life Prostate Cancer: Adjuvant Hormonal Therapy for High Risk or Very High Risk Prostate Cancer Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients Psoriasis: Clinical Response to Oral Systemic or Biologic Medications Quality of Life Assessment For Patients With Primary Headache Disorders Quantitative Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) for Breast Cancer Patients Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques Radical Prostatectomy Pathology Reporting Radiology: Exposure Dose or Time Reported for Procedures Using Fluoroscopy Radiology: Inappropriate Use of “Probably Benign” Assessment Category in Screening Mammograms Radiology: Reminder System for Screening Mammograms Radiology: Stenosis Measurement in Carotid Imaging Reports Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2) Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2) Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) Who Die While in Hospital Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post Operative Day #2) Rate of Open Repair of Small or Moderate Abdominal Aortic Aneurysms (AAA) Where Patients Are Discharged Alive Rate of Open Repair of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7) Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS) Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA) Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis Rheumatoid Arthritis (RA): Functional Status Assessment Rheumatoid Arthritis (RA): Glucocorticoid Management Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity Rheumatoid Arthritis (RA): Tuberculosis Screening Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG) Screening Colonoscopy Adenoma Detection Rate Screening for Osteoporosis for Women Aged 65-85 Years of Age Sentinel Lymph Node Biopsy for Invasive Breast Cancer Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy Sleep Apnea: Assessment of Sleep Symptoms Sleep Apnea: Positive Airway Pressure Therapy Prescribed Sleep Apnea: Severity Assessment at Initial Diagnosis Statin Therapy at Discharge after Lower Extremity Bypass (LEB) Statin Therapy for the Prevention and Treatment of Cardiovascular Disease Stroke and Stroke Rehabilitation: Discharged on Antithrombotic Therapy Stroke and Stroke Rehabilitation: Thrombolytic Therapy Surgical Site Infection (SSI) Tobacco Use and Help with Quitting Among Adolescents Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation Trastuzumab Received By Patients With AJCC Stage I (T1c) – III And HER2 Positive Breast Cancer Receiving Adjuvant Chemotherapy Tuberculosis (TB) Prevention for Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain Unplanned Hospital Readmission within 30 Days of Principal Procedure Unplanned Reoperation within the 30 Day Postoperative Period Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older Use of High-Risk Medications in the Elderly Use of Imaging Studies for Low Back Pain Varicose Vein Treatment with Saphenous Ablation: Outcome Survey Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
