Can Registry Reporting Negatively Impact Your MIPS Score?

How is that even possible? The Registry submission method, which includes Qualified registries as well as Qualified Clinical Data Registries (QCDRs), has more Quality measures available for reporting than all the other submission methods. Additionally, registry submission is also eligible for Certified EHR Technology (CEHRT) bonus aka End-to-End reporting bonus. It does sound preposterous. But don’t dismiss the possibility yet.

What exactly is end-to-end reporting bonus?

Can Registry Reporting Negatively Impact Your MIPS Score? This post goes in detail of end-to-end reporting bonus aka CEHRT bonus that is available for all submission methods except Claims. 

Let’s first look at what constitutes end-to-end reporting as it’s a bit confusing. Just because it is called CEHRT bonus, using certified EHR during some part of the data gathering and reporting process is not enough. Data for a quality measure must be gathered and reported electronically without manual intervention to earn one bonus point for that measure.

Which means, it is not enough just to use certified health IT to support patient care and capture data electronically in it. The process must be electronic end-to-end, with no manual abstraction or input involved at any step. If you manually abstract data from your certified EHR, and enter it into a web portal or abstraction input app offered by your registry, you lose the end-to-end reporting bonus.

You also lose this bonus even after gathering data using CEHRT and transmitting it to a third-party using appropriate data standards (QRDA, CCDA, API), if the third-party intermediary reports the MIPS approved quality measures using a manual manipulation of a file into a web portal.

If you have to report 6 measures, that is a straight 6 point hit to your MIPS score. Given that every point of your MIPS score will impact your payment adjustment, it is worth paying close attention. Does the registry you are using, offer a seamless electronic reporting with no manual intervention required? Check with your registry before it is too late.

Quality measure score is also impacted by benchmarks

The score for each quality measure is a sum of the score for that measure and the bonus points. The max points that you can earn for a measure depends on a couple of things: Data completion criteria met – report on 50% of your patients for all payers that satisfy the denominator criteria for the measure; Minimum case volume of 20 met; Performance rate (Numerator/Denominator); Eligible bonus points; and the Measure benchmark.  

All other criteria being met, the maximum points you can earn for a measure depend on the measure’s benchmark – its presence as well as its absence.

Benchmark Present: Each measure has a different benchmark for every eligible submission method, including Registry. So the points earned for a similar performance could vary significantly. We discussed this in detail in an earlier post

Benchmark Absent: Although registries have some innovative quality measures to offer, which might be a perfect fit for your practice, some measures might not have benchmarks yet. If there is no existing benchmark for a measure, you can only earn 3 points + the bonus points despite the 100% performance and satisfying data completeness and minimum case volume criteria. That doesn’t mean you shouldn’t report those measures. Actually, reporting them will work in your favor in the long term as the data you submit will help in benchmark creation. You can report as many measures as you like. CMS will use the six measures that work best in your favor to determine your MIPS Score. Do you know what those six measures are for you for 2017? 

How to find those six measures?  

You can’t tell which measures will turn out to be the best ones for you without comparing more than six measures. MyMipsScore helps you do exactly that. You can plug in the numbers for all the measures that make sense for your practice and analyze them to figure out which measures earn the highest score. The best measures for your practice can change over the course of year with changes in the performance rate. MyMipsScore enables you to monitor all the measures and your MIPS score throughout the year so you know where you stand at all times. 

We are here to help you evaluate your options and make informed decisions.  


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