Quality: Traditional MIPS Requirements

2022 Quality Requirements

30% OF FINAL SCORE

This percentage can change due to Special Status, Exception Applications or Alternative Payment Model (APM) Entity participation.

This page reviews Quality requirements for Traditional MIPS. To learn about Quality requirements under the APM Performance Pathway (APP), visit APP Quality Requirements.

What Quality Data Should I Submit?

Merit-based Incentive Payment System (MIPS) Quality Measure Data

You must collect measure data for the 12-month performance period (January 1 - December 31, 2022).

There are 6 collection types for MIPS quality measures:

• Electronic Clinical Quality Measures (eCQMs)
• MIPS Clinical Quality Measures (CQMs)
• Qualified Clinical Data Registry (QCDR) Measures
• Medicare Part B claims measures
• CMS Web Interface measures
• The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Survey.

General reporting requirements (for those not reporting through the CMS Web Interface):

• You’ll typically need to submit collected data for at least 6 measures (including 1 outcome measure or high-priority measure in the absence of an applicable outcome measure), or a complete specialty measure set.
• You’ll need to report performance data for at least 70% of the patients who qualify for each measure (data completeness).
• You can submit measures for different collection types (except CMS Web Interface measures) to fulfill the requirement to report a minimum of 6 quality measures.

We’ll automatically calculate and score individuals, groups, and virtual groups on 3 administrative claims measures when the individual, group, or virtual group meets the case minimum and clinician requirement for the measures.

• Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-based Incentive Payment System (MIPS) Eligible Groups. (This measure is available for groups and virtual groups only).
• Risk-standardized Complication Rate (RSCR) following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) for Merit-based Incentive Payment System (MIPS).
• NEW: Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions.

Electronic Health Record (EHR)-based Quality Reporting

If you transition from one EHR system to another EHR system during the performance year, you should aggregate the data from the previous EHR system and the new EHR system into one report for the full 12 months prior to submitting the data. If a full 12 months of data is unavailable (for example if aggregation isn’t possible), your data completeness must reflect the 12-month period. If you’re submitting eCQMs, both EHR systems must meet the 2015 Edition CEHRT criteria, the 2015 Edition Cures Update criteria, or a combination of both.

Specialty Measure Sets

If you choose to submit a specialty measure set, you must submit data on at least 6 measures within that set. If the set contains fewer than 6 measures, you should submit each measure in the set.

CMS Web Interface

If your group, virtual group, or APM Entity participating in traditional MIPS registers for the CMS Web Interface, you must report on all 10 required quality measures for the full year (January 1 - December 31, 2022).

As finalized in the CY 2022 Physician Fee Schedule Final Rule, the 2022 performance period will be the last year the CMS Web Interface will be available for quality measure reporting through traditional MIPS.

CAHPS for MIPS Survey

If your group, virtual group, or APM Entity participating in traditional MIPS registers for and meets the sampling requirements for the CAHPS for MIPS Survey, this may count as 1 of the 6 required measures or can be reported in addition to the 10 measures required for the CMS Web Interface.

How Should I Submit Data?

There are 4 submission types you can use for quality measures. The submission types are:

• Medicare Part B claims
• Sign in and upload
• CMS Web Interface
• Direct submission via Application Programming Interface (API)

Determine how to submit data using your submitter type below.

You’re a MIPS Eligible Clinician

You’re a Representative of a Group, Virtual Group, or APM Entity

* CMS Web Interface only

You’re a Third-Party Intermediary

How Are Measures Scored?

We determine measure achievement points by comparing performance on a measure to a measure benchmark.

If a measure can be reliably scored against a benchmark, it generally means:

• A benchmark is available.
• Has at least 20 cases.
• It meets the data completeness requirement standard, which is generally 70%.
• CMS Web Interface measures are scored against the Medicare Shared Savings Program benchmarks.

Bonus Points

As finalized in the CY 2022 Physician Fee Schedule Final Rule, we’re removing bonus points for end-to-end electronic reporting and reporting additional outcome/high priority measures. This will allow for a shift towards a more simplified scoring standard focused on measure achievement.

Six bonus points will still be added to the quality performance category score for clinicians in small practices who submit at least 1 measure, either individually or as a group or virtual group. This bonus isn’t added to clinicians or groups who are scored under facility-based scoring.

You may also earn up to 10 additional percentage points based on your improvement in the quality performance category from the previous year.

When Will Facility-Based Measures Scoring Apply?

Facility-based scoring isn't available for the 2022 performance year. Learn more.

Additional Resources