The CMS Performance page allows you to review your performance rate for each quality measure. It also allows you to view terms and factors that contribute to your overall Quality category score.
The list of measures includes 5 columns that represent aspects of your quality performance:
1. Total Instances. These instances are eligible or partially eligible based on the visit data provided to MIPSpro. Total instances include incomplete instances that show partial eligibility.
2. Complete Instances. These instances include complete information to determine eligibility and performance. Your complete instances are used to calculate your performance rate.
3. Met. These are a part of the Complete Instances. These instances met performance criteria per the CMS measure specification.
4. Exclusions. These instances are a part of the Complete Instances. These instances met the measure’s exclusion criteria. They won't count toward or against your performance.
5. Not Met. These also make up a part of the Complete Instances. These instances failed to meet performance.
For inverse measures, a Not Met status is positive performance and will yield points for the measure. A Met status is considered poor clinical control and will reduce the performance and points received for the measure.
The sum of the Met, Exclusions, and Not Met instances for a measure equals the number in the Complete Instances column. For example, if a provider had 20 Complete Instances, then the sum of the Met, Exclusions, and Not Met is 20.
Clicking a number under 1 of the 5 columns will take you to the Visits page. You'll see a filtered view of visits included in the count that you clicked on the CMS Performance page.
If there's a difference between the Total Instances and Complete Instances for a measure, then there are incomplete visits. Use the filter functionality on the Visits page to filter for Met, Not Met, Excluded, Ineligible, and Incomplete visits by measure.
You can also use the Gaps in Care Report to generate a report that will show the Not Met and Incomplete visits included in the measure calculation for a measure.
Performance Rate
The Performance Rate column shows the percentage of visits that met performance out of your total instances. MIPSpro calculates this percentage based on the quality visit information you provide.
Decile score
Click Decile to see the decile score view. This view shows the deciles for all selected measures and how your performance ranks based on CMS benchmarks.
Some measures won't have information here because CMS didn't have enough information to calculate a historical benchmark before the beginning of the performance year. In these cases, there may be no benchmark set by CMS at the end of the year. They also could calculate a benchmark at the end of the year if enough providers submit the measure as part of their QPP participation.
The points you receive for each quality measure correspond to the decile score. You can explore these further on the Quality Points page.
This article was updated Nov. 18, 2024.