2020 MIPS Process and Performance Reports

The MIPS Process and Performance Reports provide the information needed to manage the process of evaluating MIPS eligibility, collecting PROs, and informing clinical performance of patients being treated in your clinic for the 2020 MIPS performance year. Click a link below to jump to the details for each of the individual 2020 MIPS Reports or the frequently asked report questions.

  1. Process Report: Patient Cases without a Completed PRO
  2. Process Report: Eligible Patient Cases with One Completed PRO
  3. Performance Report: Compliance & Quality Performance by Organization TIN
  4. Performance Report: Compliance & Quality Performance by Provider NPI
  5. Frequently Asked Questions 

 

PROCESS REPORTS

Patient Cases without a Completed PRO

This report highlights MIPS eligible patient cases that don't have a completed PRO form. Use this report to identify the patient cases negatively impacting your compliance rate.

ASSUMPTION

  • Every patient case should have a completed MIPS Qualification Form indicating eligibility and either have a completed corresponding MIPS PRO or be identified as disqualified.
  • To satisfy the MIPS Data Completeness (compliance) requirement, a Patient Reported Outcome (PRO) measure must be provisioned on 70% of all patients eligible for the corresponding PRO measure(s) and who do not have any exclusions. 
  • To establish a patient's eligibility, one of the MIPS Qualification Forms must be completed for every initial evaluation a patient attends (either the MIPS Qualification Clinic Form in clinic or the Pre-Visit Patient Form completed in the app).

INCLUSION CRITERIA - PATIENT WHO:

  • Completed an initial evaluation
  • Doesn't have a completed PRO associated with the case

EXCLUSION CRITERIA - PATIENT WHO:

  • Is under the age of 18
  • Has been disqualified
  • Has a completed MQF indicating the Region of Injury as "Other"

 

REPORT COMPONENTS & DEFINITIONS

Component Definition
measure Abbreviated PRO Name
mqf_classification MQF Response - Region of Injury Classification 
insurance_answer MQF Response - Patient Insurance Provider 
first_mqf_completed Date of First Record MIPS Qualification
organization_id Account ID
name Account Name
location_name Location Name
practitioner_id Primary/Supervising Therapist ID
practitioner_first_name Primary/Supervising Therapist First Name
practitioner_last_name Primary/Supervising Therapist Last Name
patient_id Keet Patient User ID
external_patient_ID EMR Patient ID
first_name Patient First Name
last_name Patient Last Name
date_of_birth Patient Date of Birth
age Patient age extracted from the date of the initial evaluation
gender Patient Gender
ie_appointment_date EMR Initial Evaluation Appointment ID
episode_of_care_id Episode of Care ID generated by Keet

 

Eligible Patient Cases with One Completed PRO

This report identifies MIPS eligible patient cases with only one completed PRO. Use this report to monitor these patients to ensure a Discharge PRO is completed at the end of treatment.

ASSUMPTION

  • Patients identified as MIPS eligible with only one PRO may have been lost to follow up (ie self-discharge) and may require intervention to collect the discharge PRO.

INCLUSION CRITERIA - PATIENT WHO:

  • Completed an initial evaluation
  • Has a case identified as MIPS eligible
  • Has one completed PRO associated with the case

EXCLUSION CRITERIA - PATIENT WHO:

  • Is under the age of 18
  • Has been disqualified
  • Is not being treated for a region of injury corresponding to a MIPS PRO (completed MQF indicates the Region of Injury as "Other")
  • Has completed two or more MIPS PRO forms for an assigned outcome measure 

 

REPORT COMPONENTS & DEFINITIONS

Component Definition
organization_id Account ID
name Account Name
location_name Location Name
practitioner_id Primary/Supervising Therapist ID
practitioner_first_name Primary/Supervising Therapist First Name
practitioner_last_name Primary/Supervising Therapist Last Name
patient_id Patient User ID
external_patient_ID EMR Patient ID
first_name Patient First Name
last_name Patient Last Name
date_of_birth Patient Date of Birth
age Patient age extracted from the date of the initial evaluation
gender Patient Gender
ie_appointment_id EMR Initial Evaluation Appointment ID
episode_of_care_id Episode of Care ID generated by Keet
measure Abbreviated PRO Name
mqf_classification MQF Response - Measure and Body Region
first_score First recorded value / PRO Score for an episode of care
first_pain_score First recorded value / PRO NPRS Score for an episode of care
first_questionnaire_completed Date first PRO completed

  

 

PERFORMANCE REPORTS

Compliance & Quality Performance by Organization TIN

Use this report to monitor Compliance and Quality performance by organization TIN for the 10 MIPS PRO measures (5 Primary Measures and 5 related National Pain Scale Score).

ASSUMPTION

  • This report includes the overall YTD compliance and quality performance data at the Organizational TIN level. Following the completion of the reporting year, this is the data that will be submitted to CMS if you select either the Group or Both reporting type options.

INCLUSION CRITERIA - PATIENT WHO:

  • Completed an initial evaluation
  • Has a case identified as MIPS eligible
  • Has 2 or more completed PROs associated with the case (specific to quality performance, not compliance)

EXCLUSION CRITERIA - PATIENT WHO:

  • Is under the age of 18
  • Has been disqualified
  • Is not being treated for a region of injury corresponding to a MIPS PRO (completed MQF indicates the Region of Injury as "Other")

 

REPORT COMPONENTS & DEFINITIONS

Component Definition
organization_id Account ID
tin EIN - TIN, Tax ID or Employer Identification
performance_year MIPS Reporting Year
compliance_rate Compliance Rate Calculated by TIN
measure Abbreviated PRO Name
measure_id IROMS PRO or NPRS code
eligible_population Number of eligible patients who completed an Initial Evaluation on or after 01-01-2020
eligible_population_exclusion Number of eligible patients who completed less than 2 PRO surveys for the corresponding measure
eligible_population_exception Number of eligible patients identified as disqualified in accordance with the CMS guidance criteria
progressed_population Number of eligible patients who met or exceeded the measure Minimal Clinically Important Difference (MCID)
ftp_population Failed to Progress (FTP) - number of eligible patients who failed to meet the measure MCID
ftp_rate Population of non-excluded/excepted eligible patients that DID NOT meet the MCID for the measure
meets_case_req Indicates if the minimum of 20 cases required per measure has been met (TRUE) or not (FALSE). 

 

Compliance & Quality Performance by Provider NPI

Use this report to monitor Compliance and Quality performance by individual provider for the 10 MIPS PRO measures (5 Primary Measures and 5 related National Pain Scale Score).

ASSUMPTION

  • This report includes the overall YTD compliance and quality performance data by individual provider NPI. Following the completion of the reporting year, this is the data that will be submitted to CMS if you select the Individual reporting type.

INCLUSION CRITERIA - PATIENT WHO:

  • Completed an initial evaluation
  • Has a case identified as MIPS eligible
  • Has 2 or more completed PROs associated with the case (specific to quality performance, not compliance)

EXCLUSION CRITERIA - PATIENT WHO:

  • Is under the age of 18
  • Has been disqualified
  • Is not being treated for a region of injury corresponding to a MIPS PRO (completed MQF indicates the Region of Injury as "Other")

 

REPORT COMPONENTS & DEFINITIONS

Component Definition
organization_id Account ID
tin EIN - TIN, Tax ID or Employer Identification
practitioner_id Primary/Supervising Therapist ID
practitioner_first_name Primary/Supervising Therapist First Name
practitioner_last_name Primary/Supervising Therapist Last Name
extneral_id Primary/Supervising Therapist EMR ID
npi Primary/Supervising Therapist NPI
performance_year MIPS Reporting Year
compliance_rate Compliance Rate Calculated by TIN
measure Abbreviated PRO Name
measure_id IROMS PRO or NPRS code
eligible_population Number of eligible patients who completed an Initial Evaluation on or after 01-01-2020
eligible_population_exclusion Number of eligible patients who completed less than 2 PRO surveys for the corresponding measure
eligible_population_exception Number of eligible patients identified as disqualified in accordance with the CMS guidance criteria
progressed_population Number of eligible patients who met or exceeded the measure Minimal Clinically Important Difference (MCID)
ftp_population Failed to Progress (FTP) - number of eligible patients who failed to meet the measure MCID
ftp_rate Population of non-excluded/excepted eligible patients that DID NOT meet the MCID for the measure
meets_case_req Indicates if the minimum of 20 cases required per measure has been met (TRUE) or not (FALSE). 

 

  

FREQUENTLY ASKED QUESTIONS

  • Where do I locate the MIPS reports?
    • Learn where to locate your MIPS reports here.
  • How frequently are the reports updated?
    • The reports are updated weekly. 
  • Who can access the MIPS reports?
    • Care team members with an Admin profile can access the MIPS reports. 
  • How do I update a missing or incorrect Therapist NPI?
    • The MIPS Process and Performance reports organize data by individual provider National Provider Identifier (NPI). If a therapist's NPI is incorrect or missing in the MIPS reports, learn how to add or update an NPI in this Edit a Therapist User article.
  • How do I update a missing or incorrect organization Tax ID (TIN)?
    • The MIPS Process and Performance reports organize data by Organization Tax Identification Number(s) (TIN). If the organization TIN is incorrect or missing in the MIPS reports, learn how to add or update the Tax ID by Clinic in this Edit Clinic Information article.
    • If your organization has multiple Tax ID, please ensure you update the Clinic information for each location to reflect the appropriate Tax ID for that Clinic. 
  • How do I update the Primary Therapist for a patient that is associated with an incorrect Therapist?
  • Why is each PRO measure listed twice by organization TIN and Individual NPI?

    The PRO measure is listed twice once for the PRO measure and again for the corresponding PRO numeric pain scale rating (NPRS). 

    • KOS - IROMS 11
    • KOS NPRS - IROMS 12
    • LEFS- IROMS 13
    • LEFS NPRS- IROMS 14
    • NDI- IROMS 15
    • NDI NPRS- IROMS 16
    • MDQ- IROMS 17
    • MDQ NPRS- IROMS 18
    • DASH- IROMS 19
    • DASH NPRS- IROMS 20