Reporting Guide for CRNAs

2020 MIPS Quality Performance

Category

MIPS Reporting Categories

APR2020 2

2020 Quality Performance Category

Reweighting

45% final Score

(for CRNAs reporting

PI* with applicable Cost

Measures)

70% final Score

(for CRNAs NOT

reporting PI*, but with

applicable Cost

Measures)

85% of final score

(for CRNAs NOT

reporting PI* with NO

applicable Cost

Measures)

*PI: Promoting Interoperability

APR2020 3

Quality Performance Category

• Replaced the Physician Quality Reporting System

(PQRS)

• Measures health care processes, outcomes and patient

experiences of their care

• Make up the largest part (45%) of the MIPS Final Score

• CRNAs can report Quality data as individuals or as part

of groups

• Data is collected for the entire calendar year (January 1st

through December 31st)

APR2020 4

MIPS 2020 Full Participation

Requirements

Category weight = 45% Reweight = 70% (not reporting PI)

Reweight = 85% (no PI/Cost)

What you need to do

For all CRNAs: Report on at 6 applicable measures including 1 outcome or high priority measure for at least 70% of ALL your patients for FULL calendar year

Performance Category

Subject to

Reweight

QUALITY-- 45%

APR2020

2020 Anesthesia MIPS Quality Measures

6

08FEB2019

ID# Measure Title Measure Type High Priority

44 Coronary Artery Bypass Graft (CABG): Preoperative Beta-locker in Patients with Isolated CABG Surgery

Process No

76 Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections

Process Yes

404 Anesthesiology Smoking Abstinence IntermediateOutcome

Yes

424 Perioperative Temperature Management Outcome Yes

430 Prevention of Post-Operative Nausea and Vomiting (PONV)-Combination Therapy—Adults

Process Yes

463 Prevention of Post-Operative Vomiting (POV)-Combination Therapy—Pediatrics

Process No

477* Multimodal Pain Management Process Yes

*New measure for 2020

APR2020

Quality Data Collection Types

The six collection types for Quality Measures are:

• Electronic clinical quality measures (eCQMs)

• MIPS Clinical Quality Measures (CQMs)

• Qualified Clinical Data Registry (QCDR) measures

• Medicare Part B measures

• CMS Web Interface measures

• The Consumer Assessment of Healthcare Providers and

Systems (CAHPS) for MIPS Survey*

https://qpp.cms.gov/mips/how-to-register-for-CMS-WI-and-CAHPS

APR2020 7

Quality Measure Benchmarks

• Benchmarks are specific to the collection type.

• CMS awards between 3 and 10 points for each measure

in the Quality performance category.

• The measure points awarded are based on a benchmark

calculated from previous data. Benchmark data is

available on the CMS Quality Payment Program website.

• New measures that do not have a benchmark will be

awarded only 3 points.

8

08FEB2019

APR2020

Benchmarks Are Used to Determine

Measure Achievement Points

APR2020 9

Qualified Clinical Data Registry (QCDR)

Reporting May Be a Better Option for

MIPS

QCDRs

• Allows CRNAs to fulfill the Quality Category requirements with anesthesia QCDR measures

AND

• Provides opportunities for

completing and attesting

to several Improvement

Activities

Claims/EHR/Registry

• CRNAs are limited to MIPS measures for meeting the QualityCategory requirements

AND

• CRNAs will have to find

appropriate activities to fulfill

the Improvement Activities

Category

APR2020

Data Completeness and Bonus Points

• The small practice bonus is 6 points for MIPS ECs who

submit data for at least one quality measure. The bonus

will be added to the Quality performance category score.

• Small practices can receive up to 3 points for reporting

quality measures that do not meet data completeness

requirements (reporting on least 70% of all patients).

• Two bonus points can be awarded for reporting outcome

and patient experience measures.

• One point can be awarded for other high-priority

measures that meet data completeness and case

minimum requirements.

11

08FEB2019

APR2020

Additional Resources

• Quality Payment Program website: https://qpp.cms.gov

• QPP Resource Library:

https://qpp.cms.gov/about/resource-libary

• 2020 Quality Quick Start Guide

• Technical Assistance: https://qpp.cms.gov/about/help-

and-support

• E-mail: QPP@cms.hhs.gov

• Phone: 1-866-288-8292 (Monday through Friday)

APR202012