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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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Schinley Land
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2567355098
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Cullman Regional Medical Center
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Not measure related
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Not measure related
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Not measure related
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Not measure related
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CMS0159v13
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Not measure related
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Not measure related
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Not measure related
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2025 MIPS Submission
Hi. Our organization is working on our MIPS submission for 2025. Can you provide insight regarding the threshold/minimum denominator criteria for CMS-159v13/NQF-0710e/QPP-370 (Combined Population Total): Depression Remission at Twelve Months? We see the following guidance: Scoring Quality Measures
We score each measure by comparing your performance to a benchmark. If a measure can be reliably scored against a benchmark, it means: • A benchmark is available. • The measure met the case minimum criteria (at least 20 denominator-eligible instances for most measures); and • The measure met the data completeness criteria (performance data reported for at least 75% of the denominator-eligible patients/cases).
Our denominator for the questioned measure is over 20 as per guidelines. However, we notice that the scoring indicates the measure needs to met "case minimum criteria" and that a denominator of 20 is eligible for "most measures". Would a denominator of at least 20 on Measure CMS-159v13/NQF-0710e/QPP-370 (Combined Population Total): Depression Remission at Twelve Months be scored/considered as met case minimum or is there another threshold for this measure?