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  1. eCQM Issue Tracker
  2. CQM-7629

Further assistance needed in reporting CMS 2 at the individual level

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    • Icon: EC eCQMs - Eligible Clinicians EC eCQMs - Eligible Clinicians
    • Resolution: Answered
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      Thank you for your inquiry regarding CMS2v13 Preventive Care and Screening: Screening for Depression and Follow-Up Plan. Whether all four providers or just providers B and C meet the numerator is dependent on how they report the measure to CMS’ MIPS program. If each clinician is reporting data to CMS as an individual, the measure will be reported based on individual performance for the clinicians who choose the measure. If this is the case at your facility, then only providers B and C meet the numerator. If the facility is participating as a group, the aggregated measure performance of all clinicians billing under your TIN will be reported. If this is the case at your facility, the measure will be attributed to every qualifying clinician billing under the TIN (e.g., all four providers).
       
      For more information on measure attribution and calculation as it relates to reporting, please refer to Individual or Group Participation (https://qpp.cms.gov/mips/individual-or-group-participation).
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      Thank you for your inquiry regarding CMS2v13 Preventive Care and Screening: Screening for Depression and Follow-Up Plan. Whether all four providers or just providers B and C meet the numerator is dependent on how they report the measure to CMS’ MIPS program. If each clinician is reporting data to CMS as an individual, the measure will be reported based on individual performance for the clinicians who choose the measure. If this is the case at your facility, then only providers B and C meet the numerator. If the facility is participating as a group, the aggregated measure performance of all clinicians billing under your TIN will be reported. If this is the case at your facility, the measure will be attributed to every qualifying clinician billing under the TIN (e.g., all four providers).   For more information on measure attribution and calculation as it relates to reporting, please refer to Individual or Group Participation ( https://qpp.cms.gov/mips/individual-or-group-participation ).
    • CMS0002v13

      On reviewing some previous tickets, we are seeing conflicting information regarding the reporting of eCQM CMS 2 as an individual provider.

      This ticket presents a scenario with four providers (A, B, C, and D). The resolution states that only providers B and C will meet the numerator.
      https://oncprojectracking.healthit.gov/support/browse/CQM-6304 

      This later ticket references the same scenario, but now says that all four will meet the numerator.
      https://oncprojectracking.healthit.gov/support/browse/CQM-6624 

      My first question is, which of these answers is correct?

      Next, we could use some assistance around which electronic data should be used when calculating this measure at the individual level. This would be more general guidance, as most EC measures are patient-based rather than encounter-based. Assuming the answer to my previous question is that all four providers should meet the numerator, which electronic data should be used by the calculation engine to correctly produce these results? Only provider A's data for provider A's report, only provider B's data for provider B's report, and so forth? Seems some providers would see an unfair performance decrease in patient-based measures in that case. So, should each provider's report be based on data for the whole TIN? That doesn't seem right either (and would seem to fall more in line with group-level reporting).

      I see several other tickets related to this measure and the resolutions all emphasize that this is a "patient-based measure" and thus the criteria only needs to be met once in the measurement period for the patient to meet the numerator. This is all well and good, except we do not report a list of patients and which measures they met; we report measure performance scores for a provider.

      For the MIPS CQM collection type, this is simplified by the use of HCPCS codes indicating specific measure outcomes. But eCQMs must rely on a set of electronic clinical data, and are calculated electronically. 

      What is the best way for us to ensure the providers are receiving appropriate credit for these types of measures?

            AIR EC eCQM Team AIR EC eCQM Team
            jordoyne@dynamichealthit.com Jessica Ordoyne
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