Internal Training Documents

Quality Measures FAQs

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Quality Measures Release 18.1 — 2/9/2018 1 Quality Measures FAQ Reporting Year 2017 February 9, 2018 Contents What is the difference between eCQM and Registry? .................................................................................................... 2 SPH Augmented Registry Measures .......................................................................................................................... 2 How do I select measures? ............................................................................................................................................ 2 Quality performance category..................................................................................................................................... 2 Advancing Care Information performance category ................................................................................................... 2 Improvement Activities performance category ............................................................................................................ 2 Select measures that best fit your practice ................................................................................................................. 4 How are measures assessed and how are points awarded? ......................................................................................... 4 How do I report? ............................................................................................................................................................. 5 Who is responsible for reporting? ................................................................................................................................... 5 Thresholds .................................................................................................................................................................. 5 Low volume threshold ............................................................................................................................................. 5 Are resident physicians excluded from MIPS? ............................................................................................................... 5 Should I report as an individual or with a group? ........................................................................................................... 5 Individual reporting ..................................................................................................................................................... 5 Group reporting .......................................................................................................................................................... 6 What if I change groups during the performance period? .............................................................................................. 6 Physicians practicing under more than one TIN ......................................................................................................... 6 How do I decide whether to report as part of a group? .................................................................................................. 7 Example scenarios ..................................................................................................................................................... 7 Attestation Submission Mechanism Checklist ................................................................................................................ 7 QCDR Data Validation Audit Process (MIPS Program: 2017 Data Validation and Auditing) ......................................... 8 Validation criteria ........................................................................................................................................................ 8 Potential Audits .............................................................................................................................................................. 8 References ..................................................................................................................................................................... 8

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