2021 Performance Period Suppressed Merit-based Incentive Payment System (MIPS) Quality Measures


2021 Performance Period Suppressed Merit-based Incentive Payment System (MIPS) Quality Measures

Policies on Suppressing Certain Quality Measures

The following measures are excluded from a MIPS eligible clinician’s total measure achievement points and total available measure achievement points: (i) each submitted CMS Web Interface-based measure that meets the data completeness requirement, but does not have a benchmark or meet the case minimum requirement, or is redesignated as pay-for-reporting for all Shared Savings Program accountable care organizations by the Shared Savings Program; and (ii) each administrative claims-based measure that does not have a benchmark or meet the case minimum requirement. 42 C.F.R. §​ 414.1380(b)(1)(i)(A)(2).

Beginning with the 2019 MIPS performance period, for each measure that a MIPS eligible clinician submits that is significantly impacted by clinical guideline changes or other changes that CMS believes may result in patient harm or misleading results, the total available measure achievement points are reduced by 10 points. 42 C.F.R. §​ 414.1380(b)(1)(vii)(A).Quality Measure Number/TitleCollection Type ImpactedSuppression Rationale

Measure 001: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)

Medicare Part B Claims

Quality Measure Implementation Resulting in Misleading Result: The 2021 Medicare Part B Claims measure specification includes quality data codes (3051F and 3052F) that were not activated during the annual Current Procedural Terminology​ (CPT) Category II update process.

Suppression Rationale: Due to the inactive quality data codes and the subsequent inability to report such codes, CMS determined that this measure has undergone a significant change that may result in misleading results. Without these available numerator options, the measure will not allow clinicians to report the numerator of the measure appropriately and will hold clinicians, groups, and/or virtual groups accountable for performance that may not be reflective of the actual care provided. Therefore, this measure will be suppressed within the Medicare Part B Claims collection type in accordance with §​ 414.1380(b)(1)(vii)(A).

Measure 111: Pneumococcal Vaccination Status for Older Adults

Medicare Part B Claims

MIPS Clinical Quality Measure (CQM)

Electronic Clinical Quality Measure (eCQM)

Updated Guidelines: Guidelines have been revised to allow 20-valent pneumococcal conjugate vaccine by itself or the 15-valent vaccine followed by the 23-valent vaccine for adults aged 65 years or older who have not received a pneumococcal conjugate vaccine before — or whose vaccination status is unknown — and people aged 19 to 64 years who have an underlying medical condition or other risk factors and who also have not received a pneumococcal vaccine.

Truncation Rationale: Due to the updated guidelines allowing the use of 15 – or 20-valent pneumococcal conjugate vaccine, this measure will likely produce misleading results for the last quarter of the performance period. The current measure specifies that only PCV13 or PPSV23 vaccine (or both) will meet the quality action. Therefore, this measure will be truncated to the first 9 months of the performance period for the Medicare Part B claims and MIPS CQM collection types in accordance with § 414.1380(b)(1)(vii)(A).

Measure 117: Diabetes: Eye Exam

Medicare Part B Claims

Quality Measure Implementation Resulting in Misleading Result: The 2021 Medicare Part B Claims measure specification includes quality data codes (2023F, 2025F, and 2033F) that were not activated during the annual Current Procedural Terminology​ (CPT) Category II update process.

Suppression Rationale: Due to the inactive quality data codes and the subsequent inability to report such codes, CMS determined that this measure has undergone a significant change that may result in misleading results. Without these available numerator options, the measure will not allow clinicians to report the numerator of the measure appropriately and will hold clinicians, groups, and/or virtual groups accountable for performance that may not be reflective of the actual care provided. Therefore, this measure will be suppressed within the Medicare Part B Claims collection type in accordance with 42 CFR § 414.1380(b)(1)(vii)(A).

Measure 128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

eCQM

Quality Measure Implementation Resulting in Misleading Result: During the 2021 performance period, a misalignment was identified between the numerator header in the measure narrative and the numerator logic. Due to a change in the CQL, the timing for documenting the quality action changed and, according to the CQL definition, may in some circumstances extend beyond the end of the measurement period. Clinicians, groups, and/or virtual groups may submit data per the defined time except when the quality action takes place beyond the end of the performance period.

​ ​

Suppression Rationale: Due to the inability to accurately submit the quality action and the misalignment between the measure narrative and logic, CMS determined that this measure has undergone a significant change that may result in misleading results. Due to the logic revisions, clinicians, groups, and/or virtual groups will not receive credit for a follow-up plan documented in PY2022 and would fail the measure because reporting would show as no follow-up documented. Therefore, this measure will be suppressed within the eCQM collection type in accordance with 42 CFR § 414.1380(b)(1)(vii)(A).

Measure 134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan

CMS Web Interface

Quality Measure Implementation Resulting in Misleading Results: CMS determined that coding changes made to the 2021 PREV-12 were substantive changes to the measure.​

The modifications removed the Systematized Nomenclature of Medicine (SNOMED) codes that recognized the rescreening of a patient using an additional standardized depression screening tool as a means of meeting the performance criteria for implementing an appropriate follow-up plan specific to a patient with a positive depression screening.

Suppression Rationale: The coding changes no longer allow clinicians to meet the performance criteria of implementing a follow-up plan without providing an appropriate follow-up plan to the patient (patient would not be eligible for the measure numerator). For the 2021 performance period, the following will apply to the PREV-12 measure:

Excluded from the Merit-based Incentive Payment System (MIPS) scoring in accordance with §414.1380(b)(1)(i)(A)(2)(i) provided that the measure meets the data completeness requirement and the data applicable to the measure is reported via the CMS Web Interface.

Contact the Quality Payment Program at 1-866-288-8292 or by e-mail at: QPP@cms.hhs.gov (Monday-Friday 8 a.m.- 8 p.m. Eastern Time [ET]). To receive assistance more quickly, please consider calling during non-peak hours—before 10:00 a.m. and after 2:00 p.m. ET.

  • Customers who are hearing impaired can dial 711 to be connected to a TRS Communications Assistant.

CMS Approves Performance Period Truncation of the 2021 Performance Period for Quality Measure #111: Pneumococcal Vaccination Status for Older Adults Merit-based Incentive Program (MIPS) Clinical Quality Measure (CQM), Medicare Part B Claims, and Electronic Clinical Quality Measure (eCQM) Collection Types to the First 9 Months of Data

CMS will truncate the performance period to the first 9 months of data for the Medicare Part B claims, MIPS clinical quality measure (CQM), and electronic clinical quality measure (eCQM) collection types for measure Q111: Pneumococcal Vaccination Status for Older Adults.

At the October 20, 2021 meeting, the Advisory Committee on Immunization Practices (ACIP) approved, by majority vote, to update the pneumococcal vaccine recommendations. The revised recommendation no longer aligns with the current posted measure specifications for the Medicare Part B claims, MIPS CQM, and eCQM collection types, as numerator compliance is achieved through administration or previous receipt of either the pneumococcal conjugate vaccine (PCV) 13 or pneumococcal polysaccharide vaccine (PPSV23) vaccine (or both). ACIP now recommends:

  • Adults 65 and older with no previous receipt of or unknown status of vaccination should receive the PCV20 or PCV15 vaccine.
    • If PCV15 is administered, this should be followed by a dose of PPSV23.
  • Adults aged 19 – 64 with certain underlying conditions of risk-factors with no previous receipt of or unknown status of vaccination should receive the PCV20 or PCV15 vaccine.
    • If PCV15 is administered, this should be followed by a dose of PPSV23.

Therefore, CMS is truncating the performance period for the Medicare Part B claims, MIPS CQM, and eCQM collection types for this measure to the first 9 months of data in accordance with § 414.1380(b)(1)(vii)(A). MIPS eligible clinicians do not need to submit any additional documentation, and CMS will assess the measure for these collection types based upon the first 9 months of data.​


You’re getting this message because you subscribed to get email updates from the Centers for Medicare & Medicaid Services (CMS).

Update your subscriptions, modify your password or email address, or stop subscriptions at any time on your Subscriber Preferences Page. You will need to use your email address to log in. If you have questions or problems with the subscription service, please contact subscriberhelp.govdelivery.com.

This service is provided to you at no charge by Centers for Medicare & Medicaid Services (CMS).


Leave a Comment

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s