Excerpted from “MIPS 2024, Part 1—What’s New With Quality" (EyeNet, January 2024), posted online ahead of print.
As in past years, you may earn points for reporting quality measures, with your score for a measure depending on how your performance rate compares with the measure’s benchmark. CMS uses 2022 performance data to try to establish 2024 benchmarks for clinician-reported quality measures. The agency said that it expects to publish those benchmarks in late January.
Data completeness criteria stay at 75%. CMS had initially proposed increasing the data completeness criteria from 75% to 80% in 2024 but now says that it expects to keep it at 75% until at least 2026. (Note: When reporting a quality measure, you must meet both the 75%–data completeness criteria and a 20 patient–case minimum in order to earn points based on your performance rate.)
CMS clarifies that CEHRT must be used to report eCQMs. In earlier rule making, CMS had inadvertently removed language indicating that certified EHR technology (CEHRT) must be used to report electronic clinical quality measures (eCQMs). The agency reintroduced such language and added that the CEHRT must meet the Base EHR criteria (see “PI’s New CEHRT Policy”).
CMS can be more flexible in its response to ICD-10 changes. Each year, CMS adds and removes ICD-10 codes, with most of those changes taking effect on Oct. 1. This can have repercussions for quality measures because, for example, the removal of ICD-10 codes might change the types of patient who are included in a measure’s denominator. In some cases, these updates could mean that it is no longer fair to compare your performance on a measure with the measure’s historical benchmark. If CMS determines that this is the case, it can either “suppress” the measure or base your performance rate on the first nine months of the year, before the Oct. 1 changes were implemented. In past years, these interventions might have been triggered if the lists of codes in a quality measure’s numerator, denominator, exclusions, and exceptions changed by more than 10%. In 2024, instead of using that 10% threshold, CMS will consider the overall impact that code changes have on a measure.
Changes to the quality measure inventory. CMS added 11 quality measures, made substantive changes to dozens of quality measures, and removed some quality measures, including many qualified clinical data registry (QCDR) measures. Below are the changes that are most likely to impact ophthalmology practices.
Check the specs. Each year, you should review the specifications of the measures that you plan to report. To review the specifications for an IRIS Registry QCDR measure, go to the Benchmarks Summaries list and click on the measure's title. To review the specifications for eCQMs, MIPS CQMs, and claims measures, use the CMS Explore Measures & Activities tool for 2024. Measure specifications also will be included in the 2024 IRIS Registry Preparation Kit, which will be published later this year.
Manual Reporting Via the IRIS Registry
Don't have EHR? Verana Health has announced that it will provide Academy members with an option to report MIPS quality measures manually via the IRIS Registry for the 2024 MIPS performance year, with a fee charged for each clinician. This reverses an earlier decision that would have made 2023 the last year for manual reporting. Questions? Email irisdatalink@veranahealth.com.
New Quality Measures
For IRIS Registry users, three new retina measures. CMS approved three new retina measures, which you will be able to report manually via the IRIS Registry but not via IRIS Registry–EHR integration:
- 499: Appropriate Screening and Plan of Care for Elevated Intraocular Pressure Following Intravitreal or Periocular Steroid Therapy
- 500: Acute Posterior Vitreous Detachment Appropriate Examination and Follow-Up
- 501: Acute Posterior Vitreous Detachment and Acute Vitreous Hemorrhage Appropriate Examination and Follow-Up
Removal of Quality Measures
In addition to CMS reducing the inventory of QCDR measures (see below), some non-QCDR measures are no longer available for the IRIS Registry.
14: Age-Related Macular Degeneration: Dilated Macular Examination. CMS removed measure 14 because it had been topped out for several years. CMS considers process-based measures to be topped out when they have a median performance rate of at least 95%. The agency is concerned that such measures offer little opportunity for performance improvement.
128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan. CMS incorporated BMI screening and follow-up into a new composite measure—497: Preventive Care and Wellness.
138: Melanoma: Continuation of Care. CMS removed measure 138 because, like measure 14, it had been topped out for several years.
402: Tobacco Use and Help With Quitting Among Adolescents. CMS removed measure 402 because it is duplicative of measure 226: Tobacco Use: Screening and Cessation Intervention.
493: Adult Immunization Status. The measure involves reporting a patient’s status on a range of immunizations, not all of which are recorded in an ophthalmology practice’s EHR.
A More Limited Inventory of QCDR Measures
While reporting MIPS quality measures via the IRIS Registry continues to be the least onerous option for MIPS reporting, there are fewer measures to choose from than in 2023. Due to more stringent testing requirements, many QCDRs will be offering a reduced inventory of quality measures in 2024, and the IRIS Registry is no exception.
Choose from 14 QCDR measures. This year, you will be able to report 14 QCDR measures via the IRIS Registry:
- IRIS1: Endothelial Keratoplasty: Postoperative Improvement in BCVA to 20/40 or Better
- IRIS2: Glaucoma: IOP Reduction
- IRIS13: Diabetic Macular Edema: Loss of Visual Acuity
- IRIS17: Acute Anterior Uveitis: Post-Treatment Grade 0 Anterior Chamber Cells
- IRIS23: Refractive Surgery: Patients With a Postoperative Uncorrected Visual Acuity (UCVA) of 20/20 or Better Within 30 days
- IRIS24: Refractive Surgery: Patients With a Postoperative Correction Within ± 0.5 Diopter (D) of the Intended Correction
- IRIS35: Improvement of Macular Edema in Patients With Uveitis
- IRIS38: Endothelial Keratoplasty : Dislocation Requiring Surgical Intervention
- IRIS39: Glaucoma: IOP Reduction Following Trabeculectomy or an Aqueous Shunt Procedure
- IRIS50: Amblyopia: Interocular Visual Acuity
- IRIS54: Complications After Cataract Surgery
- IRIS58: Improved Visual Acuity After Vitrectomy for Complications of Diabetic Retinopathy Within 120 Days
- IRIS61: Visual Acuity Improvement Following Cataract Surgery and Minimally Invasive Glaucoma Surgery
- IRIS62: Regaining Vision After Cataract Surgery
Changes to two measure identifiers. In 2023, IRIS61 and IRIS62 were identified as IRIS55 and IRIS59, respectively, but were renumbered after undergoing substantive changes.
Next: MIPS 2024—What’s New With Promoting Interoperability
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