Measure Selection: Which MIPS measures should your organization report?

  1. Analyze provider/practice utilization to understand the patient population (i.e., conditions treated, services rendered, etc.).
  2. Evaluate existing technology to determine data capture and reporting readiness for relevant measures.
  3. Interview key personnel to further understand the aspects of MIPS most meaningful to the provider/practice (i.e., as may align to measures within each of quality, CPIA, ACI, cost and resource use).
  4. Determine ACI exemption eligibility (e.g., ≥75% hospital-based services, ≤100 “patient-facing” encounters).
  5. Recommend specific MIPS measures for participation.

Readiness Assessment: What do you need to do to prepare for MIPS?

  1. Evaluate level of staff and clinician MIPS awareness.
  2. Evaluate existing PQRS and MU processes for capture and reporting[1].
  3. Review 2015 QRUR to understand existing cost and quality measure performance[2].
  4. Determine EHR-reporting eligibility (i.e., 2014 or 2015 edition)[3].
  5. Identify high-performing areas and areas to be strengthened.
  6. Recommend reporting submission method (e.g., claims, qualified registries, certified EHR technology).

Score Calculation: How will you score MIPS?

  1. Generate a sample report of the required data for all chosen MIPS measures for a minimum 90 day period and generated by the selected reporting submission method.
  2. Evaluate the complete and accurate reporting of each measure.
  3. Calculate Quality score for the sample measure set up to 80-90 points (depending on group size) towards 60% of the overall MIPS score (or 85% if ACI-exempt).
  4. Calculate ACI score for the sample measure set up to 100 points towards 25% of the overall MIPS score (or 0% if ACI-exempt).
  5. Calculate CPIA score for the sample measure set up to 40 points towards 15% of the overall MIPS score.
  6. Calculate overall sample MIPS score to ensure neutral participation at a minimum, or at the required level to meet higher-performing provider/practice goals.

[1] Physician Quality Reporting System (PQRS) (; Meaningful Use (MU) (

[2] 2015 Quality and Resource Use Report (QRUR) (

[3] 2014 Edition Electronic Health Record (EHR) Certification Criteria (; 2015 Edition EHR Certification Criteria (