MVP Data Collection
Measure and activity data may be collected the same way for both traditional MIPS and MVPs. On this page, we highlight key tips to keep in mind for MVP data collection, most of which are relevant for traditional MIPS as well.
Data Collection Tips
General
Applies to MVPs and traditional MIPS
- Determine if you’ll work with a third party intermediary, such as a Qualified Clinical Data Registry (QCDR) (download the 2024 QCDR Qualified Posting), or a Qualified Registry (download the 2024 Qualified Registry Qualified Posting). These organizations can often provide support, such as determining how you’ll fulfill MIPS requirements, facilitating data collection & submission, and more.
- Keep in mind that the “Foundational” layer is meant to identify requirements that are consistent across all MVPs (e.g., all measures are required to fulfill the Promoting Interoperability performance category across all MVPs).
Quality
Applies to MVPs and traditional MIPS
- Make sure you can meet case minimum (at least 20 denominator eligible instances) for the required number of measures (4 when reporting an MVP). If you don’t meet case minimum, you’ll receive 0/10 points, unless you’re a small practice. You may want to report an additional quality measure if you’re unsure you’ll meet the case minimum.
- Review the collection typesfor your selected measures to make sure you can support the associated collection type(s); download the 2024 Quality Performance Category: Learning About Collection Types to learn more about collection types and their associated requirements.
- You’ll need to select your population health measure during MVP registration, but you don’t need to report any data for this measure.
- As an administrative claims measure, we’ll collect and calculate the data for you.
- If the selected population health measure can’t be calculated, we’ll exclude the measure from scoring. (This is different than the outcomes-based administrative claims measure that can be included as 1 of the 4 required measures.)
- Keep in mind that, although your selected population health measure doesn’t count towards the 4 required quality measures, your performance on the measure will be included in your quality score (if you meet the case minimum).
If participating as a subgroup, think about how you’ll aggregate the quality measure data for the clinicians in the subgroup, excluding data from any clinicians that aren’t in the subgroup.
Improvement Activities
Applies to MVPs and traditional MIPS
If reporting as a group/subgroup, identify the clinicians who will perform your selected improvement activity(ies) (at least 50% of clinicians in the group/subgroup need to perform each activity).
Promoting Interoperability
Applies to MVPs and traditional MIPS
Review your special statuses on the QPP Participation Status tool. If you qualify for certain special statuses, you might be exempt from this performance category (e.g., small practices are automatically exempt from the Promoting Interoperability performance category).
Cost
Applies to MVPs and traditional MIPS
- Remember that you don’t need to report any data for cost measures; we’ll collect and calculate the data for you (if you meet the case minimum).
- If you don’t meet the case minimum for any of the cost measures in your selected MVP, we’ll reweight the cost performance category to 0%.
MVP Data Submission
The process of data submission for MVPs will be similar to data submission for traditional MIPS. On this page we highlight some tips to keep in mind when preparing for MVP data submission.
Data Submission Tips
General
Applies to MVPs and traditional MIPS
- Make sure you sign in during the submission period (Early January - Late March) to review data submitted on your behalf. You can’t submit new or corrected data after the submission period closes.
- For all performance categories, check that your data submission files (e.g., Quality Reporting Data Architecture Category III (QRDA III) or QPP JavaScript Object Notation (JSON) file) are properly formatted; if you are unsure, consider working with athird party intermediaryfor support.
- You can only submit data for MVPs for which you have registered. If you haven’t registered, check out Learn about MVP Registration to get started.
- Your MVP submission(s) must include the relevant MVP identifier (MVP ID), and subgroup identifier if applicable.
- If you’re reporting both traditional MIPS and an MVP, make sure to report completely (i.e., submit data for all performance categories) for each reporting option.
If your practice is participating in multiple ways (e.g., as a group and subgroup), make sure to report completely (i.e., submit data for all performance categories) for each
participation option.Quality
- The Eligible Measure Applicability (EMA) process doesn’t apply to MVP reporting and won’t reduce your number of required measures in an MVP. Note: This is a change from traditional MIPS.
- If you’re a small practice reporting quality measures through Medicare Part B claims for an MVP, you’ll need to append the MVP ID to at least one claim during the performance year.
You don’t need to submit any data for your selected population health measure; we’ll collect and calculate the data for you.
Improvement Activities
Applies to MVPs and traditional MIPS
- Ensure that each activity selected and attested to is completed and documented accurately and in accordance with the guidance provided in the MIPS Data Validation document.
Maintain documentation for each activity you attested to for a period of 6 years as evidence of attestation in the event of a CMS audit.
Promoting Interoperability
Applies to MVPs and traditional MIPS
- If you qualify for reweighting but submit data anyway, you’ll override your reweighting, and you’ll be scored in this performance category.
If you report Promoting Interoperability data through multiple submission types (e.g., manual entry and file upload) and there is any conflicting data, you will receive a score of 0 out of 25 for the performance category.
Cost
Applies to MVPs and traditional MIPS
You don’t need to submit any data for any cost measures; CMS will collect and calculate data for you.