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Quality Measures User Guide

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Medicare MIPS Module: Measures | Measures Page: Grid View June 2018 Quality Measures 18.3 10-6 User Guide v1.4 Expanding Measure Information in Grid View As in Rich View, you can click on a measure to expand it for further information and greater detail. To expand measure information Click the arrow to the left of the measure's name. The entry expands to display the Quality ID and a description of the measure. Performance Rate Performance rate, as a percentage. Performance Rate = Performance Met / (Performance Met + Performance Not Met). QCDR Benchmark Client-defined benchmark, either self-chosen or picked from deciles as defined by CMS. Variance The percentage by which the performance rate differs from the performance goal. Performance Met The number of patients who meet the measure. Click the link to display the patient list. Performance Not Met The number of patients who did not meet the measure. Click the link to display the patient list. Denominator The eligible population (Initial Patient Population - Denominator Exclusions). Click the link to display the patient list. Denominator Exclusions The number of patients with conditions that should cause them to be removed from the measure population and denominator before determining if numerator criteria are met. (Patients with bilateral lower extremity amputations would be denominator exclusions for a measure requiring foot exams.) Denominator Exceptions The number of patients with conditions that should remove a patient, procedure, or unit of measurement from the denominator of the performance rate only if the numerator criteria are not met. For example, patients with an allergy to flu vaccine would be a denominator exception for influenza vaccination, but would not negatively impact the performance rate. Reporting Rate Reporting Rate = (Performance Met + Performance Not Met + Denominator Exception) / Eligible Denominator. CMS Decile The decile for the measure, as defined by CMS. Each benchmark is presented in deciles, and points are awarded within each decile. Clinicians with a performance rate in the first or second decile receive three points. Clinicians in the third decile receive 3.0–3.9 points, and so on until the 10th decile. # to Next Decile The number of patients for whom the measure must be met in order to advance to the next decile ranking. Can be at a patient level, visit level, procedure level, or episode level, depending on the measure. Reporting Providers The number of reporting providers. TABLE 10-1. Measures Grid (Continued) Column Description

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