Policies on Suppressing Certain Quality Measures

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 001: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) Medicare Part B Claims Quality Measure Implementation Resulting in Misleading Result: The 2021 Medicare Part B Claims measure specification includes quality data codes (3051F and 3052F) that were not activated during the annual Current Procedural Terminology (CPT) Category II update process.

Suppression Rationale: Due to the inactive quality data codes and the subsequent inability to report such codes, CMS determined that this measure has undergone a significant change that may result in misleading results. Without these available numerator options, the measure will not allow clinicians to report the numerator of the measure appropriately and will hold clinicians, groups, and/or virtual groups accountable for performance that may not be reflective of the actual care provided. Therefore, this measure will be suppressed within the Medicare Part B Claims collection type in accordance with § 414.1380(b)(1)(vii)(A).

Measure 111: Pneumococcal Vaccination Status for Older Adults Medicare Part B Claims

MIPS Clinical Quality Measure (CQM)

Electronic Clinical Quality Measure (eCQM)

Updated Guidelines: Guidelines have been revised to allow 20-valent pneumococcal conjugate vaccine by itself or the 15-valent vaccine followed by the 23-valent vaccine for adults aged 65 years or older who have not received a pneumococcal conjugate vaccine before — or whose vaccination status is unknown — and people aged 19 to 64 years who have an underlying medical condition or other risk factors and who also have not received a pneumococcal vaccine.

Truncation Rationale: Due to the updated guidelines allowing the use of 15 – or 20-valent pneumococcal conjugate vaccine, this measure will likely produce misleading results for the last quarter of the performance period. The current measure specifies that only PCV13 or PPSV23 vaccine (or both) will meet the quality action. Therefore, this measure will be truncated to the first 9 months of the performance period for the Medicare Part B claims and MIPS CQM collection types in accordance with § 414.1380(b)(1)(vii)(A).

Measure 117: Diabetes: Eye Exam Medicare Part B Claims Quality Measure Implementation Resulting in Misleading Result: The 2021 Medicare Part B Claims measure specification includes quality data codes (2023F, 2025F, and 2033F) that were not activated during the annual Current Procedural Terminology (CPT) Category II update process.

Suppression Rationale: Due to the inactive quality data codes and the subsequent inability to report such codes, CMS determined that this measure has undergone a significant change that may result in misleading results. Without these available numerator options, the measure will not allow clinicians to report the numerator of the measure appropriately and will hold clinicians, groups, and/or virtual groups accountable for performance that may not be reflective of the actual care provided. Therefore, this measure will be suppressed within the Medicare Part B Claims collection type in accordance with 42 CFR § 414.1380(b)(1)(vii)(A).

Measure 128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan eCQM Quality Measure Implementation Resulting in Misleading Result: During the 2021 performance period, a misalignment was identified between the numerator header in the measure narrative and the numerator logic. Due to a change in the CQL, the timing for documenting the quality action changed and, according to the CQL definition, may in some circumstances extend beyond the end of the measurement period. Clinicians, groups, and/or virtual groups may submit data per the defined time except when the quality action takes place beyond the end of the performance period.

 

Suppression Rationale: Due to the inability to accurately submit the quality action and the misalignment between the measure narrative and logic, CMS determined that this measure has undergone a significant change that may result in misleading results. Due to the logic revisions, clinicians, groups, and/or virtual groups will not receive credit for a follow-up plan documented in PY2022 and would fail the measure because reporting would show as no follow-up documented. Therefore, this measure will be suppressed within the eCQM collection type in accordance with 42 CFR § 414.1380(b)(1)(vii)(A).

 

Measure 134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan CMS Web Interface Quality Measure Implementation Resulting in Misleading Results: CMS determined that coding changes made to the 2021 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 2021 performance period, the following will apply to the PREV-12 measure:

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.

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.

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