MIPS Reporting

What’s the Deal with the 2022 MIPS Quality Measure Changes?

As we are getting close to the midway point of the MIPS performance year 2022, physicians ought to be actively collecting and reporting data on their Quality metrics. Under the MIPS program, the Centers for Medicare and Medicaid Services (CMS) will periodically revise the list of quality indicators that MIPS-eligible doctors and groups are permitted to report. A number of the metrics in the inventory are either added to or removed from the list, while others undergo significant modifications. This article provides a summary of major changes that have been made to the 2022 Quality Measures in order to assist clinicians in ensuring that their data collection and reporting are proceeding in the appropriate manner.

Reporting on Quality for MIPS

Clinicians who take part in the traditional MIPS program are required to gather and report data on quality indicators that are pertinent to their practice on an annual basis. In the Quality performance category of MIPS, a clinician’s performance is evaluated based on the health care processes.  Results, and patient experiences that are associated with their care.  For small practices that don’t report the Promoting Interoperability category. As a result, maximizing the Quality score will be an important factor in meeting the higher minimum performance. Threshold of 75 MIPS points this year.

As in the previous years,

Physicians are required to select at least six Quality measures (including one outcome or high priority measure).  One specialty measure set, and report each measure on at least seventy percent of eligible patients regardless. of the type of insurance they have. Because the Quality category includes a performance period that spans 12 months (January 1, 2022, through December 31, 2022), physicians are required to gather data for each measure over the entirety of the calendar year.

Through the Eligible Measures Applicability (EMA) Process, physicians may be able to submit fewer than six measures. And yet be eligible for the full Quality reward. This is only the case in limited circumstances. For instance, in order to comply with EMA requirements. An anesthesiologist may be required to report only four quality metrics (404, 424, 430, and 463) to a registry.

In addition, certain specialist measure sets mandate the reporting of fewer than six metrics (Electrophysiology, Hospitalists, Radiation Oncology, and Speech-Language Pathology). A hospitalist, for instance, is only required to report five different indicators (5, 8, 76, 47, and 130).

Changes to the MIPS Quality Measures Coming in 2022

For the 2022 performance period, there are a total of 200 different MIPS Quality measures that can be reported. At the beginning of each new performance year, CMS updates the Quality measure inventory with any new or revised measures. P3Care’s website www.p3care.com

Measures That Will Cause Substantial Alterations

Every quality metric comes with its own unique set of requirements. Which may also shift from one year to the next. The individual measure specifications are detailed descriptions of the quality measures. And they include information on the eligible population (the denominator) as well as the defined quality actions. That is expected for each patient, procedure, or other units of measurement for the eligible population (numerator).

There are 87 existing MIPS quality measures, and for the current performance year, those metrics have been changed. The measure specifications for each of the measures that are being reported should be thoroughly reviewed by the clinicians. In the following paragraphs, we have provided a few examples of measure modifications. That have been highlighted for certain widely reported measures.

Scoring of the 2022 Quality Measures

The performance of a clinician on a measure is compared to a national benchmark in order to calculate. The number of points that are awarded to the measure. If the following conditions are met, clinicians and organizations have the potential to earn between three and ten points for each quality measure they submit:

  • Data completeness threshold: The measure is reported on at least 70 percent of eligible patients. Irrespective of the type of insurance they have, for the entirety of the calendar year;
  • Minimum number of cases: The measurement was recorded on at least 20 different cases; AND
    A past performance year serves as the benchmark for this measurement.
  •  Regardless of the case minimum or benchmark, large practices will receive 0 points on a measure.  (While those in small practices will receive 3 points). If the measure does not meet the criterion for data completeness.
  • The maximum number of points that can be earned for some measures that CMS has deemed to have “topped out” due to historically high-performance rates is seven.


Qualified Clinical Data Registry (QCDR) measures, MIPS Clinical Quality Measures (MIPS CQMs)*, electronic CQMs (eCQMs), CMS Web Interface measures, the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS survey, and Part B Claims measures each have their own benchmarks that are specific to the type of collection they come from. For quality metrics that do not have a historical benchmark, the Centers for Medicare & Medicaid Services (CMS) will develop benchmarks based on data from 2022. If there is no way to determine the benchmark, the measure can only be award a maximum. Three points (as long as data completeness criteria has been met). If CMS captures sufficient data throughout the performance, then a benchmark may be creat after the submission has been made.

There are various quality measures for 2022 that don’t compare to anything in the past. Clinicians need to do a careful analysis of the measure benchmarks to fully comprehend the scoring repercussions associated with the measures they intend to report. You can locate all of the 2022 measure benchmarks on this page.

Start Making Reports Right Away

Clinicians should carefully review the list of quality measures for 2022 in order to ensure that their measures will still be available to report in 2022 and to gain an understanding of any changes to measure specifications that may have an impact on the workflow they use to collect data and report it. Due to the fact that the performance year has almost reached its halfway point. The physicians ought to already be collecting and reporting data, or they should begin this procedure very soon. Due to the fact that the minimum reporting requirements for 2022 will be more difficult to fulfill. It is more necessary than it has ever been to monitor performance and MIPS scores throughout the year.

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