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QPP Glossary page

Glossary

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A

API

Application Programming Interface

A tool that allows third-party intermediaries, such as qualified registries and QCDRs to programmatically enter submissions data from their EHR system.

APM incentive payment

The APM Incentive Payment that an eligible clinician receives as a QP is a lump sum payment equal to 5 percent of the QP’s estimated aggregate payments for Medicare Part B covered professional services (services paid under or based on the Medicare PFS) for the prior year.

APP

APM Performance Pathway

The APM Performance Pathway (APP) is an optional MIPS reporting and scoring pathway for MIPS eligible clinicians who are also participants in MIPS APMs.

Learn more

attest

Manual entry of data during the submission period for the Promoting Interoperability and improvement activities performance categories. (E.g. Typing in numerators and denominator, or marking an action or activity as performed.)

B

benchmark

A measure benchmark is a point of reference used for comparing your Quality or Cost performance to that of other clinicians on a given Quality or Cost measure.

CMS calculates and publishes Quality benchmarks using historical data whenever possible. When there’s not enough historical data, CMS calculates a benchmark using data submitted for the performance period.

Each measure is awarded points based on where your performance falls in comparison to the benchmark.

Learn more about Quality benchmarks

bonus points

C

CAHPS

Consumer Assessment of Healthcare Providers and Systems

Consumer Assessment Of Healthcare Providers And Systems Patient surveys that rate health care experiences.

Learn more about CAHPS

CEHRT

Certified Electronic Health Record Technology

Electronic health record (EHR) technology that meets the criteria to be certified under the ONC Health IT Certification Program. CEHRT edition requirements can change each year in QPP.

To learn which EHR systems and modules are certified for the Promoting Interoperability programs, please visit the Certified Health IT Product List (CHPL) on the ONC website.

CMS web interface

A system provided by CMS to let groups, virtual groups and APM Entities of 25 or more eligible clinicians submit quality data at the beneficiary level for a specified set of measures.

Learn more about registering for the CMS Web Interface

collection type

Sets of Quality measures with comparable specifications and data completeness criteria that can be submitted for the MIPS Quality category. (For example, electronic clinical quality measures or Medicare Part B claims measures.)

Learn more about Quality requirements

conversion factor

To determine the payment rate for a particular service, the sum of the geographically adjusted Relative Value Units (RVUs) is multiplied by a Conversion Factor (CF) in dollars. Statute specifies the formula by which the CF is updated on an annual basis.

covered professional service

Services provided by professionals like clinicians and doctors that are paid under or based on the Medicare Physician Fee Schedule.

D

decertified EHRT

Decertified Electronic Health Record Technology

An electronic health record (EHR) technology that has lost its certification. Losing certification may qualify clinicians and practices for hardship exceptions.

Learn more about hardship exceptions

determination period

A 24-month period in which CMS reviews past and current Medicare Part B Claims and PECOS data to evaluate clinicians and practices for MIPS eligibility. Each determination period consists of two 12-month segments.

Learn more about MIPS determination periods

direct submission

Data submitted to CMS through a computer-to-computer interaction, such as an Application Programming Interface (API). This doesn’t include submissions by attestation or file upload.

E

eCQMs

A clinical quality measure that is captured in certified electronic health record technology (CEHRT). Data is collected in a structured, consistent format during the process of patient care.

Learn more about eCQMs

EHR

Electronic Health Records

A digital version of a patient’s paper chart, sometimes referred to as an electronic medical record (EMR). An EHR system is the software that healthcare providers use to track patient data.

end-to-end electronic reporting

Refers to measure data extracted directly from Certified EHR Technology (CEHRT) and submitted to CMS without any manual manipulation.

F

final score

An overall assessment for each MIPS eligible clinician for a performance period. The score is determined by assessing a MIPS eligible clinician’s applicable measures and activities for each performance category. The MIPS eligible clinician’s final score determines their MIPS payment adjustment.

Finalized MVP

MVP that has been finalized through the Physician Fee Schedule Final Rule and will be available for MIPS reporting in a future performance year. Recommendations or comments on finalized MVPs must be made through the MVP maintenance process.

G

group reporting

One of several MIPS participation options, where MIPS data is collected, aggregated and submitted on behalf all the clinicians in the TIN.

Learn more about individual and group participation

H

high-weighted activities

High weighted activities address areas with the greatest impact on patient care, safety, health, and well-being, or require significant investment of time and resources.

Learn more about Improvement Activities

hospital VBP

Hospital Value-Based Purchasing

A program that rewards acute care hospitals with incentive payments for the quality of care they give to people with Medicare. This program adjusts payments to hospitals under the Inpatient Prospective Payment System (IPPS) based on the quality of care they deliver.

I

individual reporting

One of several MIPS participation options, where MIPS data is collected and submitted on behalf a single clinician (identified by TIN/NPI combination).

Learn more about individual and group participation

initial eligibility

The initial release of MIPS eligibility data, typically prior to the Performance Year, reflecting segment 1 of the MIPS determination period.

Learn more about eligibility determinations

L

LVT

low-volume threshold

The volume of covered professional services, Medicare patients and associated charges a clinician or group must exceed in order to be MIPS eligible.

Learn more about low-volume threshold qualifications

Learn more about how the low-volume threshold gets calculated for clinicians, practices, and MIPS APMs

M

measure achievement points

The amount of points earned for a Quality measure when compared to the benchmark, excluding bonus points.

Learn more about Quality measures

Medicare CQMs

A collection type for Shared Savings Program ACOs that can only be reported under the APP, and requires collection and reporting of data on the ACO's Medicare fee-for-service beneficiaries instead of all payer/all patient population.

medium-weighted activities

A medium weighted activity doesn’t meet the criteria of a high-weighted activity.

Learn more about Improvement Activities

MIPS eligible clinician

A clinician who meets certain requirements and is eligible to receive a MIPS payment adjustment based on participation in MIPS as an individual, group, virtual group, or APM Entity.

View MIPS eligible criteria per year

MIPS Process

Process for Recommending Changes to Existing MIPS Measures and Improvements


There are established processes within traditional MIPS for updating existing measures and improvement activities. For example:

  • Revisions to current MIPS quality and QCDR measures would be requested by the measure stewards annually during the established processes within traditional MIPS for potential implementation.
  • Changes to MIPS quality measures may be submitted for consideration during the proposed rulemaking comment cycle, or by contacting the measure steward directly.
  • You can submit modifications to existing improvement activities through the annual Call for Measures and Activities.

If changes are made through rulemaking to existing individual measures and activities, those changes will be reflected within the MVP.

MVP Candidate

A draft MVP submitted to CMS for consideration in future rulemaking.

MVP Maintenance Process

Annual process for the general public to submit recommendations to CMS to revise previously finalized MIPS Value Pathways (MVPs). CMS will decide whether to update an MVP based on comments received; any changes would be proposed through rulemaking.

MVPs

MIPS Value Pathways

MIPS Value Pathways (MVPs) are a subset of measures and activities, established through rule-making, that can be used to meet MIPS reporting requirements.

The MVPs framework aims to align and connect measures and activities across the quality, cost, and improvement activities performance categories of MIPS for different specialties or conditions.

N

NPI

National Provider Identifier

A unique 10-digit number used to identify clinicians.

O

opt-in

Clinicians and practices can opt-in to report and receive a payment adjustment if they exceed 1 or 2 (but not all 3) of the low-volume threshold criteria as long as they aren’t otherwise exempt.

This participation option requires a formal election during the submission period.

Learn more about how opt-in eligibility is determined

Learn about next steps if you’re opt-in eligible

outcome measure

A measure that assesses patient outcomes, whether desirable or adverse, as a result of your care.

Learn more about Quality measures

P

Partial QP

Partial Qualifying Alternative Payment Model participant

A status that depends on meeting thresholds for payment amount and patient count during a Performance Year.

If a clinician is Partial QP, they have the option to report for MIPS.

Learn more about Partial QP status

Participation Option

Participation option refers to the levels at which data can be collected and submitted, or reported, to CMS for MIPS. There are 5 participation options for MIPS reporting: individual, group, virtual group, subgroup, and APM Entity.

payment adjustment

CMS applies adjustments to your Medicare reimbursements on future covered professional services based on your participation and performance in MIPS. The payment adjustment is based on the MIPS eligible clinician’s final score.

Learn more about payment adjustments

PECOS

Provider Enrollment, Chain, and Ownership System

Helps suppliers and providers manage Medicare enrollment tasks online.

CMS reviews past and current PECOS data as part of MIPS eligibility determinations, as well as identifying TINs to which we will issue QP payments.

Learn more about PECOS

performance category score

A MIPS eligible clinician's performance category score is the sum of all the measure achievement points assigned for the measures or activities required for the performance category criteria plus any applicable bonus points. The sum is divided by the sum of total available points.

performance feedback

MS provides performance feedback and payment adjustment information based on the data submitted for the previous Performance Year. Use this feedback to help improve your care and optimize the payments you receive from CMS.

performance period

The time period for which CMS assesses a clinician, group, virtual group, or APM Entity’s performance in MIPS. Each MIPS performance category has its own defined performance period.

POS codes

place of service codes

2-digit codes placed on healthcare professional claims to indicate the setting in which a service was provided. CMS maintains POS codes used throughout the healthcare industry.

PQRS

Physician Quality Reporting System

A past program in which clinicians were required to submit Quality data to CMS. The Quality category of MIPS replaces this program.

practice

A single TIN organization.

Proposed MVP

MVP that has been proposed through the Physician Fee Schedule Notice of Proposed Rulemaking that is open to comment and feedback from interested parties and the general public through the formal rulemaking comment process.

PY

Performance Year

The period in which program participants must collect QPP data. They report the data they’ve collected in the first few months of the following year.

The MIPS Performance Year begins on January 1 and ends on December 31 each year.

Learn more about Performance Year deadlines

Q

QCDR

Qualified Clinical Data Registry

A QCDR is a CMS-approved entity that demonstrates clinical expertise in medicine and quality measurement development that collects medical or clinical data on behalf of a MIPS eligible clinician for the purpose of patient and disease tracking to foster improvement in the quality of care provided to patients.

QIN-QIO

Quality Innovation Network QIN-QIOs

Free networks selected by CMS to work with providers, community partners, beneficiaries, and caregivers on improving the quality of care for people with specific health conditions.

Find your local QIN-QIO

QP

Qualifying Alternative Payment Model Participant

An eligible clinician who has met or exceeded the payment amount or patient count thresholds based on participation in an Advanced APM.

Learn more about QPs

qualified registry

A Qualified Registry is a CMS-approved entity that collects MIPS data from MIPS eligible clinicians and submits it to CMS on their behalf. Clinicians typically work directly with their chosen Qualified Registry to submit data on the selected measures or activities they have selected.

R

Reporting Options

A reporting option is a set of guidelines to follow in order to meet the MIPS reporting requirements. The 3 reporting options are (1) traditional MIPS, (2) MIPS Value Pathway (MVPs), and (3) the APM Performance Pathway (APP).

review period

S

segment

12-month eligibility assessment window in which CMS reviews past and current Medicare Part B Claims and PECOS data for clinicians and practices.

Each determination period consists of two 12-month segments.

Learn more about MIPS determination periods

small practice

A solo practitioner or a practice (TIN), virtual group or APM Entity with 15 or fewer clinicians. Clinicians, practices, virtual groups and APM Entities with the small practice special status have modified scoring and reporting requirements.

Learn more about the support available to small practices

snapshot

A date on which CMS will capture Participation Lists and Affiliated Practitioner lists. These lists will be used to identify participants in MIPS APMs and to run QP determination calculations.

Learn more about QP determinations and APM

SO

security official

A role for the Quality Payment Program system that allows the user to report data, view eligibility information for the organization, and approve other users to access the organization in the QPP system.

solo practitioner

A practice consisting of 1 clinician.

special status

An automatically applied determination by CMS that qualifies clinicians, practices, or virtual groups for reduced reporting requirements in certain performance categories.

Learn more about special statuses

specialty measure set

A group of Quality measures identified as applicable to a specific specialty.

staff user

A role for the Quality Payment Program system that allows the user to report data and view eligibility information for the organization.

submission types

Ways you can submit data based on your submitter type and the category you’re reporting.

The submission types are:

  • Medicare Part B claims
  • Sign in and attest
  • Sign in and upload
  • CMS Web Interface
  • Direct submission via API

submitter types

The type of person who submits data. This includes clinicians, groups, virtual groups and APM Entities submitting data for themselves, or someone authorized to submit data on their behalf.

T

targeted review

A process that allows clinicians, groups, virtual groups, and APM Entities to request that CMS review their final score and MIPS payment adjustment. CMS will update the final score and payment adjustment if it’s determined that a MIPS scoring policy wasn’t applied correctly.

Individuals and APM Entities may also use the Targeted review process for limited reviews of participation lists used in QP determinations.

Learn more about review deadlines

third party intermediary

An entity that has been approved to submit data on behalf of a MIPS eligible clinician, practice, or virtual group for one or more of the quality, improvement activities, and Promoting Interoperability performance categories.

TIN

taxpayer identification number

A Taxpayer Identification Number (TIN) is 9 digit identification number issued by the Internal Revenue Service (IRS) and used in Medicare billing.

QPP uses TINs found in Medicare claims as unique practice identifiers.

TIN/NPI Combination

When a clinician reassigns their Medicare billing rights to a TIN , their NPI becomes associated with that TIN. This association is referred to as a TIN/NPI combination.

TRS

telecommunication relay service

When dialing 711, you will be connected to a TRS Communications Assistant who will relay your conversation to the help desk agent with strict confidentiality.

V

virtual group

A participation option available to solo practitioners and practices with 10 or fewer clinicians that allows them to join forces and submit aggregated data for all the clinicians in the TINs.

Learn more about virtual groups

voluntary reporting

A reporting option available to a clinician, practice, or APM Entity that is not MIPS eligible but does bill Medicare Part B claims in segment 2 of the MIPS determination period. If you report voluntarily, you’ll receive limited performance feedback and a final score but no payment adjustment.