MIPS Quality – It’s All About the Numbers

Well, we’re almost two months into 2017 – the first year of MIPS!  As everyone tries to finish submitting their PQRS and Meaningful Use data for 2016, the need to make decisions about the new quality program sits on top of the To-Do list. Usually, when a new program is announced by CMS, it’s a matter of understanding the new acronyms associated with the program. PQRS is gone and has been replaced with a category named QUALITY.  

That’s the good news – it will be easy to know what you are reporting under this category of MIPS – quality measures and performance. You may have already reported certain quality measures to CMS in the past few years and they may still be good measures to report for MIPS, but MIPS is different in a few ways.

  • The level of performance reported to CMS really matters.
  • At least one outcome measure must be reported.
  • There are many numbers and mathematics that you need to understand to score big on MIPS.

So, let’s talk about the numbers you need to keep in mind when making your MIPS quality decisions.

Eligible Clinicians Reporting as a group

The clinicians who are eligible to participate in MIPS has expanded from physicians only to include NPs, PAs, CRNAs & CNS’.  Read about eligibility requirements for MIPS in our blog 13 Things to Know About MACRA.

Now, ask yourself these questions:

  1. Under how many Tax IDs do your providers submit claims to CMS?
  2. Have all of your ECs reassigned their billing rights to one Tax ID or is there more than one Tax ID that will be reporting MIPS to CMS?


ECs can submit as individuals across all MIPS categories or as a group. A group is defined by the Tax ID that their NPI is associated with.

If you choose to report as a group, you will submit data on quality measures, as well as Advancing Care Information and Improvement Activity measures, as a group. This means just one performance per measure for the entire group. The group’s fee schedule will be adjusted based on that performance. Keep that in mind as we look at the numbers associated with the Quality category of MIPS.

MIPS Reporting requirements

6.png You need to report a total of 6 quality measures to CMS.

You need to submit at least 1 outcome measure unless there is not one available in your specialty measure set. If so, you can report another high priority measure.


If you are reporting via the CMS web interface, you need to report 15 quality measures.

Note: National Quality Strategy Domain (NQS) requirements and the need to report nine measures are removed.

Reporting Methods

The number of measures available for you to choose from depends on the method of reporting you plan to use to submit quality to CMS.


Total Measures Outcome Measures High Priority Measures
Claims 74 9 42
Registry 243 69 158
CEHRT 53 7 21
CMS Web Interface 15 3 5


For QCDRs – The number of measures available depends on what measures the QCDR has been approved for and has implemented.


1.png If you choose to engage with a MIPS CAHPS Survey vendor and have patient satisfaction survey results for Medicare beneficiaries reported to CMS, reporting CAHPS will count as reporting one high priority measure and you will only need to select 5 other quality measures to report, including an outcome measure if available.



As you are accustomed to, you will report numerators, denominators, exceptions and exclusions for each measure giving you a performance rate. Although benchmarks have not been readily available in the past from CMS, your QRUR reports were intended to give you a sense of how your results compared to your peers. This year, CMS has published measure benchmarks for each measure and those benchmarks reflect performance according to the method of reporting you use. These numbers are important, so make sure you know them.

The benchmarks are divided into deciles:

3.png For 2017, the lowest decile is decile 3, meaning the lowest performance score you can earn is 3 points. You’ll get these points for reporting a measure with at least one patient in the numerator.
10.png You can earn from 3 to 10 points for each of the measures that you submit. The score you earn will be based on your performance (your numerator divided by your denominator). That performance score will place you in a certain decile range and that decile will award you between 3 and 10 points.

The level of performance varies for each measure in each decile, so you need to monitor your performance in relation to the deciles in order to have a sense of how well you are doing.

Note: To see the decile range and point association for all measures visit the QPP website education page and scroll down to the link “2017 Quality Benchmarks.”

60.png The maximum number of points that you can earn for reporting 6 quality measures is 60 points.
15.png If your group includes 15 or more clinicians, CMS will calculate the All Cause Readmission measure based on administrative claims data only if there are 200 or more attributed hospitalizations.

If this measure is calculated, an extra 10 points will be added to your quality point denominator (70) and your level of performance on this measure will be determined by CMS.

If your performance is the best possible for all 6 measures, you will earn 60 points, but should you fall short, CMS has built in the opportunity for you to earn some bonus points.

Bonus Points

6.png There is a possibility to earn 1 bonus point for each measure reported electronically to CMS, for a total of 6 bonus points for reporting by CEHRT or a reporting vendor, like Medisolv. This reporting must be end-to-end electronic reporting with no human handling of data between the EHR and CMS.
6.png There is a possibility to earn an additional 6 bonus points by choosing extra outcome or high priority measures beyond the one required outcome measure. Of your 6 measures that are reported, an extra outcome or patient satisfaction measure would earn 2 bonus points. For each measure that qualifies as a high priority measure, 1 bonus point is available.

Note: the maximum extra high priority measure points available is 6 points.

The Quality Payment Program website is a terrific resource to look up your measures by method of reporting and to determine if each measure is considered an outcome or high priority measure.

Let’s do an example caluclation together to make sense of the math.

Below is a table that illustrates the possible points available based on measure selection and submission using a CEHRT.


Measure Type Performance Decile Decile Range Points High Priority Bonus CEHRT Bonus
122v5 Diabetes:HbA1c 
Poor Control
Outcome 24.63% 5 25.62-
5-5.9 0 1
124v5 Cervical Cancer Screening Process 58.42% 9 54.78-
9-9.9 0 1
139v5 Screening for Future Fall Risk Process
High Priority
80.78% 7 63.82-
7-7.9 1 1
156v5 Use of High Risk Meds on Elderly Process
High Priority
12.34% 5 15.74-
5-5.9 1 1
159v5 Depression Remission Outcome
High Priority
1.01% 3 None 3-3.9 2 1
165v5 Controlling High Blood Pressure High Priority 59.75% 4 55.40-59.20 4-4.9 1 1
  33.0-38.40 5 6

Total Points: 41.0-49.5

Keep these numbers in mind as you carefully select your measures, ensuring that you have included at least 1 outcome measure, measures you have performed well on in the past and a few high priority measures as you compile your 6 measures to be submitted.

Choose your quality reporting vendor and understand how they will support you in the calculation of your possible MIPS points on quality, as well as the Advancing Care Information measures and Improvement Activities.

If you would like to learn more about the Medisolv MIPS solution, please contact us today.


A Beginner’s Guide to MACRA


To learn more about Medisolv’s certified Quality Reporting and Management Solution, click here. Our solution is exclusively endorsed by The American Hospital Association.

Denise Scott