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Type:
EC eCQMs - Eligible Clinicians
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Resolution: Referred to External Party for Resolution
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Priority:
Moderate
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Component/s: None
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None
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HOLLY BLACK
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3868483070
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Sightview MIPS Services
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CMS0138v13
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We are unsure if the practice will receive a score for this measure if Strata 2 has less than twenty patients in the denominator.
We have been advised by the registry that we are currently using that eCQM 226 Smoking Intervention and Cessation is reported based on Strata 1 and scoring is based on Strata 2. I am unclear on how scoring is determined if the denominator for Strata 1 is over twenty patients but the denominator for Strata 2 has less than twenty patients. Would the practice receive 0/3 points (based on practice size) or could they potentially receive 10 points if performance score was high enough?
Example:
Strata 1: 97.98% with 291/297 patients
Strata 2: 75% with 3 / 4 patients
Strata 3: 97.64% with 290/297 patients
Based on the CMS decile calculation sheet would the practice receive 6 decile points for this measure, or would they receive 0 points because they only have 4 patients in denominator for Strata 2?