The Quality component of your MIPS score is determined by data completeness and quality performance.
For 2021, the data completeness requirement is satisfied if you capture at least an initial outcome on 70% of eligible patients. To determine if you are satisfying the data completeness requirement, review the Performance Report: Compliance & Quality Performance by Organization TIN or Provider NPI and ensure the aggregate compliance rate for the year is equal to or greater than 70%. For more details, click here.
Case Minimum Requirement
For the 2021 performance year, a minimum of 20 cases are required per measure.
The quality performance is evaluated for each outcome measure by comparing each therapist's failure to progress rate to the established benchmark for that PRO. A patient fails to progress when their score change between the first and last completed PRO does not meet or exceed the defined Minimal Clinically Important Difference (MCID) for that PRO. The failure to progress rate is the # of patients who failed to progressed out of the total # of patients who submitted more than 2 forms for an assigned PRO. To review you quality performance, review the Performance Report: Compliance & Quality Performance by Organization TIN or Provider NPI reports.