Quality Measures Requirements

Let’s take a look at Quality Measures requirements.  This performance category measures health care processes, outcomes, and patient experiences of their care.  Remember that requirements have changed and will most likely continue to change each Performance Year (PY) due to policy changes.  This information comes straight from qpp.cms.gov and has been categorized for clarity.  Let us know if we can further assist in any of this information specific to your needs.

For PY 2019, Quality Requirements have been updated to comprise 45% of the final score.  This percentage can be affected by Special Statuses, Exception Applications, reweighting of other performance quality categories, or Alternative Payment Model (APM) participation.

What quality data should be submitted?  

Based on Merit-Based Incentive Payment System (MIPS), participants should collect measure data for the 12-month performance period from January 1 to December 31, 2019.  The amount of data that is required to be submitted depends on your collection type.

For the following categories, electronic Clinical Quality Measures (eCQMs), MIPS CQMs (formerly “Registry measures”), Qualified Clinical Data Registry (QCDR) Measures, and Medicare Part B claims measures (only available to small practices), participants should submit collected data for at least 6 measures, or a complete specialty measure set; and one of these measures should be an outcome measure; if you have no applicable outcome measure, you can submit another high priority measure instead.  In addition, for groups of 16 or more clinicians who meet the case minimum of 200, the administrative claims-based all-cause readmission measure will be automatically scored as a seventh measure.

Keep in mind that an individual or group can submit any combination of measures across these collection types (eCQMs, MIPS CQMs, QCDR Measures, and for small practices, Medicare Part B claims measures) to fulfill the requirement to submit 6 measures. The CAHPS for MIPS Survey measure can also count as one of the 6 measures submitted.

Specialty Measure Sets

Clinicians and groups can choose to submit a specialty or subspecialty measure set. In doing so, they must submit data on at least 6 measures within that set. If the set contains fewer than 6 measures, the clinician or group should submit each measure in the set.

CMS Web Interface

Groups and virtual groups with 25 or more clinicians, who are registered and choose to submit data using the CMS Web Interface, must report all 10 required quality measures for the full year (January 1 – December 31, 2019).


Groups and virtual groups that collect measures via various collection types (eCQMs, MIPS CQMs, QCDRs, CMS Web Interface, and for small practices, Medicare Part B claims) may also submit and be scored on the CAHPS for MIPS survey.  Groups will have their total available measure achievement points reduced by 10 points if they submit 5 or fewer measures, and register for the CAHPS for MIPS survey but do not meet the minimum beneficiary sampling requirements.

How Are Measures Scored?

This category has been updated.  Measure achievement points are determined by comparing performance on a measure to a measure benchmark.  If a measure can be reliably scored against a benchmark, it means a benchmark is available; and has at least 20 cases; and meets the data completeness requirement standard, which is generally 60 percent.

Bonus Points

Quality measure bonus points can be earned in the following ways: Submission of 2 or more outcome or high priority quality measures (bonus will not be awarded for the first outcome or high priority quality measure and will not be awarded for measures submitted via CMS Web Interface); and submission using End-to-End Electronic Reporting, with quality data directly reported from a certified EHR technology (CEHRT).  Please note that opioid-related measures are now included in high priority quality measures.

There are six bonus points added to the Quality performance category score for clinicians in small practices who submit at least one measure, either individually or as a group or virtual group.  Also, clinicians can earn up to ten additional percentage points based on their improvement in the Quality performance category from the previous year.

When Will Facility-Based Measures Scoring Apply?

Beginning with the 2019 Performance Period, we will identify clinicians and groups eligible for facility-based scoring. These clinicians and groups may have the option to use facility-based measurement scores for their Quality and Cost performance category scores.

Facility-based measurement scoring will be used for your Quality and Cost performance category scores when you are identified as facility-based; and you are attributed to a facility with a Hospital Value-Based Purchasing (VBP) Program score for the 2019 performance period; and the Hospital VBP score results in a higher score than the MIPS Quality measure data you submit and MIPS Cost measure data calculated for you.

How Should I Submit Data?

This category also has updated information.  Individual clinicians in a small practice and small practices participating as a group or virtual group can submit their quality measures through Medicare Part B Claims.  Registered groups and virtual groups, with 25 or more clinicians, can submit their quality measures through the CMS Web Interface. Individual clinicians, groups, virtual groups, and third-party intermediaries can log in and upload their quality measure data in an approved file format on qpp.cms.gov.  Authorized third-party intermediaries can perform a direct submission, transmitting data through a computer-to-computer interaction, such as an API.

Third-Party Intermediaries

A third-party intermediary collects and submits data on behalf of MIPS eligible clinicians – such intermediaries can be a qualified registry, a qualified clinical data registry (QCDR), a health IT vendor that obtains data from a MIPS eligible clinician’s CEHRT, or a CMS-approved survey vendor.  Certain CMS-approved third-party intermediaries also provide feedback to clinicians throughout the year to support and drive improvement: qualified clinical data registries and qualified registries.

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