Meeting the reporting performance rate means scoring above 0% for a measure or performing the recommended clinical quality action at least once per measure. You can also pass the performance rate for a measure with 100% exclusions reported.
MIPSpro can validate performance based on the data put into the system, with 2 exceptions:
- When reporting an inverse measure, you should aim for your performance to be as close to 0% performance as possible. This shows better clinical control.
- Consider Measure 238: Administering High Risk Medication to the Elderly, which is an inverse measure. You don't want to be administering high-risk medication to the elderly, so the more Not Met visits you have, the closer to 0% performance you'll be. That will yield you more points for this measure.
- When reporting an EMA cluster, you may need to report a measure with 0% performance.
Review your performance rate in MIPSpro on the CMS Performance page.
Reporting rate and data completeness threshold
Meeting the data completeness threshold means reporting a minimum of 75% (2024 and 2025 performance years) of eligible instances for each measure for the entire reporting year (Jan. 1-Dec. 31). This is critical for successful MIPS reporting.
The data completeness threshold rule applies to individual measures and the Eligible Measures Applicability (EMA) exception. MIPSpro doesn't have access to your claims data, so we can't verify that you've met this requirement. Your practice and CMS are the only ones who can calculate and verify that you have met the completion threshold.
We can, however, estimate your completion threshold using the visits you enter into MIPSpro. Before you submit your data, you'll be required to complete the Completion Threshold page. You'll need to enter your total eligible instances for each measure for the entire reporting year and calculate your reporting rate to ensure that you've hit the mark if you're not uploading all of your data for the year into MIPSpro.
Best practices
If you upload data via spreadsheets or have a direct EHR integration with us, meeting the requirement is usually straightforward. These methods allow you to report 100% of eligible data with little manual intervention or calculation of the reporting rate.
This article was updated Nov. 18, 2024.