Overview
This performance category measures healthcare-related processes, outcomes, and patient experiences.
Requirements may change each due to policy changes.
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Performance Year
Select your performance year.
PY 2022 APP 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 two options for what to use for your APM Performance Pathway quality submission depending on your participation level.
If you participate at this level... | You can use this collection type set... |
---|---|
Individual, Group, APM Entity (SSP ACO and non-SSP ACO) | Option 1
|
APM Entity (SSP ACOs only) | Option 2
|
*Only individuals, groups and APM Entities with the small practice designation can report Medicare Part B claims measures.
What Quality Data Should I Submit?
You must collect measure data for the 12-month (January 1 - December 31, 2022) on one of the following sets of pre-determined quality measures:
Measure # and Title |
Collection Type | Submitter Type |
---|---|---|
Quality ID: 001 |
eCQM, MIPS CQM, |
MIPS Eligible Clinician Representative of a Practice APM Entities 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 Entities 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 Entities Third Party Intermediary |
Quality ID: 321 CAHPS for MIPS |
CAHPS for MIPS Survey | Third Party Intermediary |
Measure #: 479 Hospital-Wide, 30-day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Eligible MIPS Clinician Groups |
Administrative Claims | N/A |
Measure #: 484 |
Administrative Claims |
N/A |
Measure # and Title | Collection Type | Submitter Type |
---|---|---|
Quality ID: 001 Diabetes: Hemoglobin A1c (HbA1c) Poor Control |
CMS Web Interface | APM Entities (SSP ACO) |
Quality ID: 134 Preventive Care and Screening: Screening for Depression and Follow-up Plan |
CMS Web Interface | APM Entities (SSP ACO) |
Quality ID: 236 Controlling High Blood Pressure |
CMS Web Interface | APM Entities (SSP ACO) |
Quality ID: 318 Falls: Screening for Future Fall Risk |
CMS Web Interface | APM Entities (SSP ACO) |
Quality ID: 110 Preventive Care and Screening: Influenza Immunization |
CMS Web Interface | APM Entities (SSP ACO) |
Quality ID: 226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention |
CMS Web Interface | APM Entities (SSP ACO) |
Quality ID: 113 Colorectal Cancer Screening |
CMS Web Interface | APM Entities (SSP ACO) |
Quality ID: 112 Breast Cancer Screening |
CMS Web Interface | APM Entities (SSP ACO) |
Quality ID: 438 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease |
CMS Web Interface | APM Entities (SSP ACO) |
Quality ID: 370 Depression Remission at Twelve Months |
CMS Web Interface | APM Entities (SSP ACO) |
Quality ID: 321 CAHPS for MIPS |
CAHPS for MIPS Survey | Third Party Intermediary |
Measure #: 479 Hospital-Wide, 30-day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Eligible Clinician Groups |
Administrative Claims | N/A |
Measure #: 484 UPDATED: Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions |
Administrative Claims | N/A |
CAHPS for MIPS
for MIPS is a required measure for the APM Performance Pathway.
APM Entities (SSP ACOs) will not need to register for CAHPS. However, these APM Entities (SSP ACOs) must hire a vendor.
APM Entities (non-SSP ACOs) that choose to report the CAHPS for MIPS Survey will need to register during the open registration period. If you register for the CAHPS for MIPS Survey, you will need to hire a vendor to administer the survey for you.
If your APM Entity (non-SSP ACO) only reports Traditional MIPS, reporting the CAHPS for MIPS measure is optional.
Practices (groups) reporting through the APM Performance Pathway must register for the CAHPS for MIPS survey.
The CAHPS for MIPS survey is not available to clinicians reporting the APM Performance Pathway as an individual.
Learn more and register for the CAHPS for MIPS survey
EHR-based Quality Reporting
If you transition from one system to another during the performance year, you should aggregate the data from the previous EHR and the new EHR into one report for the full 12 months prior to submitting the data. If a full 12 months of data is unavailable (for example if aggregation is not possible), your data completeness must reflect the 12-month period. If you are submitting eCQMs, both EHR systems must be 2015 Edition .
How Are Measures Scored?
If a measure can be reliably scored against a , it means:
- A benchmark is available; and
- The volume of cases you’ve submitted is sufficient (20 cases for most measures; 200 cases for the hospital readmission measure, 18 cases for the multiple chronic conditions measure); and
- You’ve met data completeness requirements (submitted data for at least 70 % of the denominator eligible patients/instances).
Bonus Points
Six bonus points are added to the Quality performance category score for clinicians who submit at least 1 APP quality measure. This bonus is not added to clinicians or groups who are scored under facility-based scoring.
You can also earn up to 10 additional percentage points based on your improvement in the Quality performance category from the previous year.