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Quality: APP Requirements

Overview

This performance category measures healthcare-related processes, outcomes, and patient experiences.

Requirements may change each  due to policy changes.

Select Performance Year

Performance Year

Select your performance year.

2024 Performance Year Quality Requirements

50% OF FINAL SCORE

This percentage can change due to special statuses, exception applications, or reweighting of other performance categories.

What Quality Data Submission Options are Available?

You have 3 options for what  to use for your Alternative Payment Model (APM) Performance Pathway (APP) quality submission depending on whether or not you’re participating as a Medicare Shared Savings Program (Shared Savings Program) Accountable Care Organization (ACO).

If you participate at this level...You can use this collection type set...
Individual, Group, APM Entity (Models/Programs, Excluding Shared Savings Program ACOs)

Option 1

  • Electronic Clinical Quality Measure (eCQM), MIPS CQM, or Medicare Part B Claims* (3 measures),
  • CAHPS for MIPS Survey, and
  • Administrative Claims (2 measures).
Shared Savings Program ACOs Only

Option 2

  • CMS Web Interface (10 measures)**,
  • CAHPS for MIPS Survey, and
  • Administrative Claims (2 measures).
Shared Savings Program ACOs Only

Option 3

  • eCQM, MIPS CQM, or Medicare CQM (3 measures)***,
  • CAHPS for MIPS Survey, and
  • Administrative Claims (2 measures).

*Only individuals, groups, and APM Entities with the small practice designation can report Medicare Part B claims measures.

**The 2024 performance period will be the final year for Shared Savings Program ACOs to report through the CMS Web Interface.

***Beginning with the 2024 performance year, (Medicare CQMs) have been established as a new collection type for Shared Savings Program ACOs that can only be reported under the APP. Under the Medicare CQM collection type, an ACO that participates in the Shared Savings Program is required to collect and report data on the ACO’s Medicare fee-for-service beneficiaries that meet the definition of a beneficiary eligible for Medicare CQMs at 42 CFR 425.20, instead of reporting on their all payer/all patient population.

What Quality Data Should I Submit?

You must collect measure data for the 12-month  (January 1 to December 31, 2024) on one of the following sets of pre-determined quality measures. You can submit pre-determined quality measures from different collection types to fulfill the reporting requirement:

Measure # and TitleCollection TypeSubmitter Type
Quality ID: 001
Diabetes: Hemoglobin A1c 
(HbA1c) Poor Control
eCQM,
MIPS CQM,
Medicare Part B 
Claims
MIPS Eligible Clinician Representative of a Practice
APM Entity 
Third Party Intermediary
Quality ID: 134
Preventive Care and Screening: Screening for Depression and 
Follow-up Plan
eCQM,
MIPS CQM,
Medicare Part B 
Claims
MIPS Eligible Clinician Representative of a Practice
APM Entity 
Third Party Intermediary
Quality ID: 236
Controlling High Blood Pressure
eCQM,
MIPS CQM,
Medicare Part B 
Claims
MIPS Eligible Clinician Representative of a Practice
APM Entity 
Third Party Intermediary
Quality ID: 321
CAHPS for MIPS Survey
CAHPS for MIPS SurveyThird Party Intermediary
Quality ID: 479
Hospital-Wide, 30-day, 
All-Cause Unplanned
Readmission (HWR) Rate
for MIPS Eligible MIPS 
Clinician Groups
Administrative ClaimsN/A
Quality ID: 484
Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions
Administrative ClaimsN/A

Download Option 1: Quality Measures Set

 

Measure # and TitleCollection TypeSubmitter Type
Quality ID: 001/DM-2
Diabetes: Hemoglobin A1c (HbA1c) 
Poor Control
CMS Web InterfaceAPM Entity 
(Shared Savings Program ACO)
Third Party Intermediary
Quality ID: 134/PREV-12
Preventive Care and Screening: 
Screening for Depression and 
Follow-up Plan
CMS Web InterfaceAPM Entity 
(Shared Savings Program ACO)
Third Party Intermediary
Quality ID: 236/HTN-2
Controlling High Blood Pressure
CMS Web InterfaceAPM Entity 
(Shared Savings Program ACO)
Third Party Intermediary
Quality ID: 318/CARE-2
Falls: Screening for Future Fall Risk
CMS Web InterfaceAPM Entity 
(Shared Savings Program ACO)
Third Party Intermediary
Quality ID: 110/PREV-7
Preventive Care and Screening: Influenza Immunization
CMS Web InterfaceAPM Entity 
(Shared Savings Program ACO)
Third Party Intermediary
Quality ID: 226/PREV-10
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
CMS Web InterfaceAPM Entity 
​​​​​​​(Shared Savings Program ACO)
Third Party Intermediary
Quality ID: 113/PREV-6
Colorectal Cancer Screening
CMS Web InterfaceAPM Entity 
​​​​​​​(Shared Savings Program ACO)
Third Party Intermediary
Quality ID: 112/PREV-5
Breast Cancer Screening
CMS Web InterfaceAPM Entity 
​​​​​​​(Shared Savings Program ACO)
Third Party Intermediary
Quality ID: 438/PREV-13
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
CMS Web InterfaceAPM Entity 
​​​​​​​(Shared Savings Program ACO)
Third Party Intermediary
Quality ID: 370/MH-1
Depression Remission at Twelve Months
CMS Web InterfaceAPM Entity 
​​​​​​​(Shared Savings Program ACO)
Third Party Intermediary
Quality ID: 321
CAHPS for MIPS Survey
CAHPS for MIPS SurveyThird Party Intermediary
Quality ID: 479
Hospital-Wide, 30-day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Eligible Clinician Groups
Administrative ClaimsN/A
Quality ID: 484
Clinician and Clinician Group 
Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions
Administrative ClaimsN/A

Download Option 2: Quality Measures Set 

 

Measure # and TitleCollection TypeSubmitter Type
Quality ID: 001SSP
Diabetes: Hemoglobin A1c 
(HbA1c) Poor Control
eCQM/MIPS
CQM/Medicare CQM
APM Entity 
(Shared Savings Program ACO)
Third Party Intermediary
Quality ID: 134SSP
Preventive Care and Screening: 
Screening for Depression and 
Follow-up Plan
eCQM/MIPS
CQM/Medicare CQM
APM Entity 
(Shared Savings Program ACO)
Third Party Intermediary
Quality ID: 236SSP
Controlling High Blood Pressure
eCQM/MIPS
CQM/Medicare CQM
APM Entity 
(Shared Savings Program ACO)
Third Party Intermediary
Quality ID: 321
CAHPS for MIPS Survey
CAHPS for MIPS SurveyThird Party Intermediary
Quality ID: 479
Hospital-Wide, 30-day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Eligible Clinician Groups
Administrative ClaimsN/A
Quality ID: 484
Clinician and Clinician Group 
Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions
Administrative ClaimsN/A

Download Option 3: Quality Measures Set 

 

CAHPS for MIPS Survey

 for MIPS Survey is a required measure for the APP.

Shared Savings Program ACOs don’t need to register for the CAHPS for MIPS Survey because they’re required to report the quality measures included in the APP. ACOs must hire a CMS-approved survey vendor to administer the survey.

APM Entities (non-Shared Savings Program ACOs) and groups reporting the APP that choose to report the CAHPS for MIPS Survey will need to register during the CAHPS for MIPS Survey registration period (April 1 to July 1, 2024). If you register for the CAHPS for MIPS Survey, you’ll need to contract with a CMS-approved survey vendor to administer the survey for you.

NEW: Beginning in the 2024 performance period, registered groups and APM Entities (including Shared Savings Program ACOs) are required to contract with a CAHPS for MIPS Survey vendor to administer the Spanish translation of the survey to Spanish-preferring patients.

If your APM Entity (non-Shared Savings Program ACO) only reports traditional MIPS, reporting the CAHPS for MIPS Survey measure is optional.

The CAHPS for MIPS Survey isn’t available to clinicians reporting the APP as an individual.

Learn more and register for the CAHPS for MIPS survey.

Electronic Health Record (EHR)-based Quality Reporting

If you transition from one system to another during the performance period, you’ll need to aggregate the data from the previous EHR system(s) and the new EHR system into one report for the full 12-month reporting period prior to submitting the data. 

If your practice uses multiple EHR systems for clinicians billing as a group under the same TIN, you’ll also need to aggregate data into a single report prior to submitting the data. If a situation arises where data for the full 12 months is unavailable (for example: data aggregation from two or more EHR systems isn’t possible due to a transition of EHR systems), you should submit as much quality data as possible. However, we want to emphasize that the 12-month performance period and 75% data completeness threshold continue to be applicable reporting requirements regardless of an EHR transition during the performance period.
 
If you’re submitting eCQMs using multiple EHR systems, the submitting EHR system must be certified to align with the Office of the National Coordinator for Health IT (ONC)’s regulations at 45 CFR 170.315  for the 2024 performance period.

How Are Measures Scored?

We determine measure achievement points by comparing performance on a measure to a measure benchmark.

If a measure can be reliably scored against a , it means:

  • A benchmark is available.
  • The volume of cases you’ve submitted is sufficient (20 cases for most measures, 200 cases for the Hospital-Wide, 30-Day, All Cause Unplanned Readmission (HWR) Rate for MIPS Eligible Clinician Groups, and 18 cases for the Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions).
  • It meets the data completeness requirements (submitted data for at least 75% of the denominator-eligible patients/instances).

Bonus Points

Six bonus points are added to the quality performance category score for clinicians in small practices who submit at least one APP quality measure, either individually or as a group; these bonus points are also available to APM Entities with the small practice designation. This bonus isn’t added to clinicians or groups who are scored under facility-based scoring.

You may also earn up to 10 additional percentage points based on your improvement in the quality performance category from the previous year.

Additional Resources