Policies on Suppressing Certain Quality Measures

Note: this information is also available on the QPP Resource Library.

The following measures are excluded from a MIPS eligible clinician’s total measure achievement points and total available measure achievement points: (i) each submitted CMS Web Interface-based measure that meets the data completeness requirement, but does not have a benchmark or meet the case minimum requirement, or is redesignated as pay-for-reporting for all Shared Savings Program accountable care organizations by the Shared Savings Program; and (ii) each administrative claims-based measure that does not have a benchmark or meet the case minimum requirement. 42 C.F.R. § 414.1380(b)(1)(i)(A)(2).

Beginning with the 2019 MIPS performance period, for each measure that a MIPS eligible clinician submits that is significantly impacted by clinical guideline changes or other changes that CMS believes may result in patient harm or misleading results, the total available measure achievement points are reduced by 10 points. 42 C.F.R. § 414.1380(b)(1)(vii)(A).

Quality Measure Number/Title Collection Type Impacted Suppression Rationale
Measure 69:

Hematology: Multiple Myeloma: Treatment with Bisphosphonates

MIPS Clinical
Quality Measures (CQM)
Guideline Change Impact: The updated National Comprehensive Cancer Network® (NCCN) Guidelines for Multiple Myeloma recommend bisphosphonates (Category 1 Recommendation) or Denosumab for all patients receiving myeloma therapy for symptomatic disease regardless of documented bone disease. For the MIPS 2019 and 2020 performance periods, providers were utilizing the denominator exception of a medical reason for the use of Denosumab, as previous guidelines recommended bisphosphonates for all patients receiving myeloma therapy for symptomatic disease, not including the option of prescribing Denosumab.

Suppression Rationale: Due to the updated guidelines and misalignment with the current measure specification, the measure will likely produce misleading results. This may lower performance and penalize clinicians for prescribing Denosumab as indicated by the NCCN Guidelines for Multiple Myeloma. Therefore, this measure will be suppressed in accordance with § 414.1380(b)(1)(vii)(A).

Measure 134:

Preventive Care and Screening: Screening for Depression and Follow-Up Plan

CMS Web Interface

Note: Web-Interface measures
utilized performance and data
completeness data based on
calculations from Shared
Savings Program (SSP).

Quality Measure Implementation Resulting in Misleading Results: CMS determined that coding changes made to the 2020 PREV-12 were substantive changes to the measure.

The modifications removed the Systematized Nomenclature of Medicine (SNOMED) codes that recognized the rescreening of a patient using an additional standardized depression screening tool as a means of meeting the performance criteria for implementing an appropriate follow-up plan specific to a patient with a positive depression screening.

Suppression Rationale: The coding changes no longer allow clinicians to meet the performance criteria of implementing a follow-up plan without providing an appropriate follow-up plan to the patient (patient would not be eligible for the measure numerator). For the 2020 performance period, the following will apply to the PREV-12 measure:

Reclassified to “pay-for-reporting” for the Shared Savings Program as provided in §425.502(a)(5); and

Excluded from the Merit-based Incentive Payment System (MIPS) scoring in accordance with §414.1380(b)(1)(i)(A)(2)(i) provided that the measure meets the data completeness requirement and the data applicable to the measure is reported via the CMS Web Interface.

Measure 419:

Overuse of Imaging for the Evaluation of Primary Headache

Medicare Part B Claims Quality Measure Implementation Resulting in Misleading Result: The 2020 Medicare Part B Claims measure specification includes a quality data code (M1030) that was inadvertently indicated to be inactivated during the Healthcare Common Procedure Coding System (HCPCS) update process. This code allowed for the exclusion of patients who should not be included in the measure performance rate; however, it could no longer be utilized on the submitted claim(s) due to inactivation.

Suppression Rationale: Due to the inability to report a quality data code, this measure will likely produce misleading results. Without an available numerator option, the measure will include patients not appropriate for the measure and hold clinicians, groups, and/or virtual groups accountable. Therefore, this measure will be suppressed within the Medicare Part B Claims collection type.

Measure 458:

All-cause Hospital Readmission

Administrative Claims Quality Measure Implementation Resulting in Misleading Result: Based on initial analytic findings for condition- and procedure-specific measures in the hospital programs, it was found that during the early months of 2020 there were statistically significant changes in cohort case mix, significantly reduced admission volumes, and deviations in observed outcomes, as compared with the same time period in 2019. Furthermore, the data showed geographic variation impacting COVID-related and non-related conditions. Given overlap with outcome measures in the hospital programs, similar impacts are expected for this measure. Specific to MIPS, the measure steward has indicated that the measures’ risk adjustment models need to be updated to account for factors outside of the clinician’s control for a comparison benchmark to be calculated or the calculation will lead to misleading results.

Suppression Rationale: Due to the public health emergency, there is geographical variance in the claims data, and the measure steward has indicated that the measures’ risk adjustment models need to be updated to account for factors outside of the clinician’s control for a comparison benchmark to be calculated, which significantly impacts the measure. Therefore, this measure will be suppressed within the Administrative Claims collection type.

Contact the Quality Payment Program at 1-866-288-8292 or by e-mail at: QPP@cms.hhs.gov (Monday-Friday 8 a.m.- 8 p.m. Eastern Time [ET]). To receive assistance more quickly, please consider calling during non-peak hours—before 10:00 a.m. and after 2:00 p.m. ET.

Customers who are hearing impaired can dial 711 to be connected to a TRS Communications Assistant.

About Author

Healthcentric Advisors
As the New England Quality Payment Program Support Center, Healthcentric Advisors assists New England-based physician and other eligible clinical practices to prepare for and participate in the new Quality Payment Program (QPP), established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).