What is the Eligible Measure Applicability process?

Most have never heard of the Eligible Measure Applicability (EMA) process and have no idea what impact it may have on MIPS reporting.

For the MIPS performance period, there are more than 250 measures available to report for the Quality performance category. Unless you’re reporting through the CMS Web Interface, the Quality performance category data submission requirements are to:

  • Submit 6 quality measures, one of which must be an outcome measure, if available. If an outcome measure is not available, then you must submit a high priority measure;

OR

  • Submit a complete specialty measure set if the specialty measure set contains less than6 measures.

The Eligible Measure Applicability process checks if there are additional clinically related quality measures you could have submitted when:

  • You’re in a small practice and you choose Medicare Part B claims as your collection type;

OR

  • You work with a third-party intermediary to collect and submit MIPS Clinical Quality Measures (CQMs):

AND

  • You submit fewer than 6 measures, or no outcome or high priority measure, and all ofyour submitted measures are either the Medicare Part B claims or MIPS Clinical QualityMeasure collection type

If you or your group don’t meet the requirements for reporting Medicare Part B claims measures or MIPS CQMs, the EMA process:

  • Determines whether you could have submitted more measures, including outcome and high priority measures;

AND

  • Adjusts scoring if needed to reflect the number of available measures.

For a Quality measure to be scored for MIPS there must be a minimum of 20 eligible instances reported. There is an exception, small practices receive three points for every measure they report but must report more than 20 for the total possible points. For each Quality measure, there are parameters. Some are based on age, gender, number of office visits in a year, etc. Let’s say you are wanting to submit a measure that requires two office visits in a year but you only have ten patients that qualify for the measure. This would be a case where the EMA process would be used if you were reporting via claims or through a third party registry. When a MIPS eligible clinician or group has less than 20 eligible instances for a Quality measure that is clinically related to the other Quality measures they are reporting, their third-party intermediary will still need to include that Quality measure in the submission.

In the instance of reporting through a registry where the MIPS eligible clinician or group doesn’t have any denominator eligible instances, the Quality measure (s) should be submitted as 0/0 (0s in the numerator and denominator). It’s important to note that this only applies when there are 0 eligible instances for a clinically related measure. Be sure to verify with your registry they will be reporting applicable measures with a 0/0. This is what you pay them to do.

Third-party intermediaries must submit a denominator that accurately reflects the MIPS eligible clinician or group’s eligible population for the measure, even if no performance data was collected.

No supporting documentation is required at submission, as the vendors attest that data they submit has been validated and is true, accurate, and complete to the best of their knowledge. If the vendor is selected for auditing, this may be one of the items audited to determine that the data submitted was true, accurate, and complete.

The first thing you want to do if you are reporting via claims or a registry and cannot find six measures that fit you will have to verify which measures CMS considers clinically relevant. To do this you will use a SingleSource file. This is a file that is available on the QPP website. You will find it in the Resource Library contained in either the claims or registry measures specifications Zip file. You will see the file within the Zip file. There are instructions on how to use the file. Essentially you will choose all of the Current Procedural Terminology CPT) codes which will give you a list of measures that are clinically relevant. You will see some that you are planning to report and possibly some you will not be reporting. You will want to get specification sheets for each measure to understand how to report it.

You may find that some of the measures CMS would consider clinically relevant you are still unable to report a denominator. If you are reporting through claims there is no way to report this situation. You will want to review your Quality performance score when it comes out. If it appears CMS included that measure you may have to submit a targeted review. In the case of reporting via a registry you will report the measure with a zero numerator and a zero denominator.

One example of this is a clinician who reads radiology reports but never sees patients face to face. There are three codes that relate to three procedural codes that are considered clinically relevant by CMS, however, one of the quality measures also requires an Evaluation and Management (E&M) code. The procedure code is relevant but there are no face to face encounters so the required inclusion of an E&M code means her number of eligible cases is zero. In reporting through a registry she will want to be sure the registry is reporting this measure with a 0/0. In the case of claims reporting you will want to verify your final score to be sure CMS counted the measure.

Another situation you may encounter is there are no Quality measures found when you use the SingleSource file. In this case the only recourse you have is to submit all other MIPS data. Once the performance scores come out and your Quality category is scored a zero you will submit a Targeted Review. CMS will accept the review as long as you have used the SingleSource file correctly.

This is a complicated process that you may need to know so you are able to get your maximum Quality score. If you suspect this applies to you and you are confused on how to address your situation please reach out. We can help.