Question

You’re doing a training for physicians; they have a general understating of MIPS, but they want to understand the measures better. You decide to give the physicians some examples, so you went to the MIPS website and selected some measures from some of the MIPS Category (see measure descriptions in Appendix A). Based on Avedis Donobedian’s model, what is the right classification (i.e., structure, process, and/or outcome) of each measure in Appendix A?

(a) From MIPS’s Quality Measures (1/2 a point each):

(1) Colonoscopy screening for patients >85:

(2) 30-day all cause hospital readmission:

(3) Percent of new patients whose biopsy results have been reviewed and communicated:

(b) From MIPS’s Improvement Activities Measures (1 point):

(1) Completion of all CDC modules on prescribing opioids:

(c) From MIPS’s Advancing Care Information Category (1 point):

(1) At least one permissible prescription written by the MIPS eligible clinician is queried for a drug formulary and transmitted electronically using certified EHR technology

Answer 1

1) Colonoscopy screening for patients above 85years :-

MIPS CLINICAL QUALITY MEASURES (CQMS)

MEASURE TYPE:

Efficiency – High Priority

DESCRIPTION:

The percentage of patients greater than 85 years of age who received a screening colonoscopy from January 1 to December 31

INSTRUCTIONS:

This measure is to be submitted each time a colonoscopy is performed for all patients during the performanceperiod. There is no diagnosis associated with this measure. This measure may be submitted by Merit-based

Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

Measure Submission Type:

Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality-data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part Bclaims data. For more information regarding Application Programming Interface (API), please refer to the Quality

Payment Program (QPP) website.

DENOMINATOR:

Colonoscopy examinations performed on patients greater than 85 years of age during the encounter period

Denominator Instructions:

MIPS eligible clinicians who indicate that the colonoscopy procedure is incomplete or was discontinued

should use the procedure number and the addition (as appropriate) of modifier 52, 53, 73, or 74. Patients

who have a coded colonoscopy procedure that has a modifier 52, 53, 73, or 74 will not qualify for inclusion

in this measure.

Denominator Criteria (Eligible Cases):

All patients greater than 85 years of age on date on encounter receiving a colonoscopy for screening purposes only

AND

Patient encounter during the performance period (CPT or HCPCS): 45378, 45380, 45381, 45384,

45385, G0121

WITHOUT

Modifier: 52, 53, 73, or 74

NUMERATOR:

All patients greater than 85 years of age included in the denominator who did NOT have a history of colorectal cancer or a valid medical reason for the colonoscopy, including: iron deficiency anemia, lower gastrointestinal bleeding,

Crohn’s Disease (i.e. regional enteritis), familial adenomatous polyposis, Lynch Syndrome (i.e., hereditary nonpolyposis colorectal cancer), inflammatory bowel disease, ulcerative colitis, abnormal findings of gastrointestinaltract, or changes in bowel habits. Colonoscopy examinations performed for screening purposes only

Numerator Instructions:

INVERSE MEASURE - A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Submitting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.

Numerator Options:

Performance Met: Patients greater than 85 years of age who did not have a history of colorectal cancer or valid medical reason for the colonoscopy, including: iron deficiency anemia, lower gastrointestinal bleeding, Crohn’s Disease (i.e., regional enteritis), familial adenomatous polyposis,

Lynch Syndrome (i.e., hereditary non-polyposis colorectal cancer), inflammatory bowel disease, ulcerative colitis, abnormal finding of gastrointestinal tract, or changes in bowel habits (G9659)

OR

Performance Not Met: Documentation of medical reason(s) for a colonoscopy performed on a patient greater than 85 years of age (e.g., last colonoscopy incomplete, last colonoscopy had inadequate prep, iron deficiency anemia, lower gastrointestinal bleeding, Crohn’s Disease (i.e., regional enteritis), familial history of adenomatous polyposis,

Lynch Syndrome (i.e., hereditary non-polyposis colorectal cancer), inflammatory bowel disease, ulcerative colitis, abnormal finding of gastrointestinal tract, or changes in bowel habits) (G9660)

OR

Performance Not Met: Patients greater than 85 years of age who received a routine colonoscopy for a reason other than the following: an assessment of signs/symptoms of GI tract illness, and/or the patient is considered high risk, and/or to follow-up on previously diagnosed advance lesions (G9661)

2) 30 days all cause readmission :-

A. Measure Name

30-day All-Cause Hospital Readmission Measure

B. Measure Description

The 30-day All-Cause Hospital Readmission Measure is a risk-standardized readmission rate for beneficiaries age 65 or older who were hospitalized and experienced an unplanned readmission for any cause to a short-stay acute-care hospital within 30 days of discharge. The measure includes solo practitioners and groups, as identified by their

Medicare Taxpayer Identification Number (TIN) as defined by the current MIPS attribution for quality measures.

This TIN-level, risk-standardized, all-cause unplanned readmission measure is adapted from a hospital-level quality measure (Horwitz et al. 2011) developed for the Centers for

Medicare & Medicaid Services (CMS) by the Yale New Haven Health Services

Corporation - Center for Outcomes Research & Evaluation (YNHHSC/CORE). This version of the measure is based on the measure updates developed for CMS by YNHHSC/CORE in 2017 with additional updates for new

International Classification of Diseases (ICD)-10 Clinical Modification (CM) codes.

C. Rationale

Some readmissions are unavoidable, but they may also result from poor quality of care, inadequate coordination of care, or lack of effective discharge planning and transitional care. CMS is applying this measure to the Merit-based Incentive Payment System (MIPS) because reducing avoidable readmissions is a key component in the effort to promote more efficient, high-quality care.

D. Measure Outcome (Numerator)

The outcome for this measure is any unplanned readmission to a non-federal, short-stay, acute-care or critical access hospital within 30 days of discharge from an index admission.

The identification of planned readmissions is discussed in section H. Readmissions during the 30-day period that follow a planned readmission are not counted in the outcome. In the case of multiple readmissions during the 30-day period, the measure counts only one outcome. If a patient is readmitted to the same hospital on the same calendar day of discharge for the same condition as the index admission, the measure considers the patient to have had one single continuous admission (that is, one index admission). However, if the condition is different from the index admission, this is considered a readmission in the measure.

E. Population Measured (Denominator)

Eligible (index) admissions include acute care hospitalizations for Medicare Fee-for-

Service (FFS) beneficiaries age 65 or older at non-federal, short-stay, acute-care or critical access hospitals that were discharged during the performance period and are not excluded for the reasons listed in the next section. Admissions for all principal diagnoses are included unless identified as having a reason for exclusion. A hospitalization that counts as a readmission for a prior stay also may count as a new index admission if it meets the criteria for an index admission.

For the purposes of measure calculation (described in section H), index admissions are assigned to one of five specialty cohorts—surgery/gynecology, general medicine, cardiorespiratory, cardiovascular, and neurology—based on diagnoses and procedure codes on the claim mapped to Agency for Healthcare Research and Quality (AHRQ)

Clinical Classifications Software (CCS); section I provides a link to methodology reports that contain the detailed CCS categories for each cohort.

3) MIPS CLINICAL QUALITY MEASURES (CQMS)

MEASURE TYPE:

Process – High Priority

DESCRIPTION:

Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient

INSTRUCTIONS:

This measure is to be submitted once per performance period for patients who are seen for an office visit and have a biopsy performed during the performance period. This measure may be submitted by Merit-based Incentive

Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

NOTE: While this measure is only required to be submitted once per eligible patient per performance period, it is recommended that the MIPS eligible clinician performing the biopsy communicates the results to the primary care/referring physician and patient each time a biopsy is done.

Measure Submission Type:

Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality-data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality

Payment Program (QPP) website.

DENOMINATOR:

All patients undergoing a biopsy

DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.

Denominator Criteria (Eligible Cases):

All patients regardless of age on date of encounter

AND

Patient procedure during the performance period (CPT): 11102, 11104, 11106, 11755, 19081, 19083, 19085, 19100,19101, 19125, 20200, 20205, 20206, 20220, 20225, 20240, 20245, 20250, 20251, 21550, 21920, 21925, 23065, 23066, 23100, 23101, 24065, 24066, 24100, 24101, 25065, 25066, 25100, 25101, 26100, 26105, 26110, 27040, 27041, 27050, 27052, 27323, 27324, 27330, 27331, 27613, 27614, 27620, 28050, 28052, 28054, 29800, 29805, 29830, 29840, 29860, 29870, 29900, 30100, 31050, 31051, 31237, 31510, 31535, 31536, 31576, 31625, 31628, 31629, 31632, 31633, 31717, 32096, 32097, 32098, 32400, 32405, 32604, 32606, 32607, 32608, 32609, 37200, 37609, 38221, 38500, 38505, 38510, 38520, 38525, 38530, 38570, 38572, 40490, 40808, 41100, 41105, 41108, 42100, 42400, 42405, 42800, 42804, 42806, 43193, 43197, 43198, 43202, 43239, 43261, 43605, 44010, 44020, 44025, 44100, 44322, 44361, 44377

AND

Patient encounter during the performance period (CPT): 99201, 99202, 99203, 99204, 99205, 99241*,

99242*, 99243*, 99244*, 99245*

WITHOUT

Telehealth Modifier: GQ, GT, 95, POS 02

NUMERATOR:

Patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and the patient by the provider and/or office and medical team. There must also be acknowledgement and/or documentation of the communication in a biopsy tracking log and document in the patient’s medical record

Definition:

Communication – Acceptable communication methods which are to be documented in the biopsy tracking log and patient medical record include:

• Directly speaking with the patient or a person designated by the patient to discuss biopsy results

• Documented telephone message or voice mail regarding the availability of biopsy results

• Mailer/fax sent to the patient indicating the availability of biopsy results or discussing the diagnosis itself

• Any HIPAA secure electronic communication with the patient discussing the biopsy results

The components of a tracking log incorporate the following-

• Initials of physician performing the biopsy

• Patient name

• Date of biopsy

• Type of biopsy

• Biopsy result

• Date of biopsy result

Numerator Instructions:

To satisfy this measure, the biopsying physician and/or office and medical team must:

• Review the biopsy results with the patient

• Communicate those results to the primary care/referring physician

• Track communication in a log

• Document tracking process in the patient’s medical record

NUMERATOR NOTE: For Denominator Exception(s), patients are ineligible for this measure if at the time of encounter there are patient reason(s) for not communicating the results to the Primary Care or referring physician (e.g. patient self-referred or has no Primary Care Physician, etc.) as further specified below.

Numerator Options:

Performance Met: Biopsy results reviewed, communicated, tracked, and documented (G8883)