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EC eCQMs - Eligible Clinicians
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Resolution: Referred to External Party for Resolution
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Moderate
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None
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None
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Penny Schmiege
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6232418713
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The CORE Institute for Research and Education
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CMS0155v12
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CMS0155v11
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Affects MIPS scores
Traditional MIPS. CMS measure specifications include CMS language "Percentage of patients 3-17 years of age who had an outpatient visit with a PCP or OB/GYN and who had evidence of ...."
I oversee MIPS for large practices, however we have no PCP or OB/GYN providers.
Our EMR, Athena Practice, collects and reports all eCQM's, including 155. I can see the measure is reported on CMS website for 2022 and 2023 (I know 2023 includes just preliminary report). I have an example for 2022. NPI 1275537607, Tharesh Udupa (podiatrist) on his individual reporting report, it shows 155 included in top 6 measures with performance rate 38.36%. However, it also displays "N/A" for points earned.
Question 1. If 155 'counts' for this provider, why are there no points?
Question 2. If 155 does not 'count' for this provider, why is it listed in top 6 measures when there were other measures reported that could have counted in his top 6 that were not included (i.e., measure 374, Closing the Referral Loop)?
Question 3. Should we expect the 2023 Preliminary reports displaying earned points for measure 155 to similarly be adjusted for the final reports for our non-PCP/OB GYN providers?
Question 4. Does CMS adjust the counting of measure 155 based on the specialty of provider that reported it?