Our Gaps in Care report allows you to make care improvements by reviewing visits marked Incomplete or Not Met.
1. Select Quality Performance from the Quality Checklist page.
2. Review your Total Instances and Complete Instances on the Quality Performance page. If you have more Total Instances than Complete Instances, you have visits missing codes to determine eligibility or performance. These are Incomplete Visits and require numerator codes to complete them.
You need to ensure at least 75% of your eligible instances are completed instances to be eligible for the measure's full points.
3. After you've determined which measures need additional data, click Quality Checklist.
4. Click Data Entry.
5. Click Patients.
6. Click Gaps in Care Report.
7. Select the options from each dropdown menu.
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Measure: Select the measure you want to complete.
- If completing multiple measures, select 1 measure at a time to create a separate report for each measure.
- Status: Select Incomplete to complete your incomplete visits.
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Visits to Display: Select Show one visit with selected status if the measure's reporting frequency is only once per patient per year. Select Show all visits with selected status if the measure's reporting frequency is more than once per patient per year.
- Visit the Completion Threshold page to view the reporting frequency for all selected messages.
8. Click Filter.
9. Click Export to download a Microsoft Excel spreadsheet featuring the visits that meet your chosen criteria.
- We recommend renaming the downloaded file with the measure number and Gaps in Care report in the name (Measure 47 Gaps in Care report, for example).
10. Open the spreadsheet and delete all columns except Patient Identifier, Last Name, First Name, DOS (Date of Service), and NPI. Patient Identifier and DOS are the only required fields.
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If you're a direct integration customer or your EHR connects directly to MIPSpro, data updates must be made in your EHR. Your EHR will send these updates to MIPSpro during the next upload. Contact Customer Support at 888-720-4100, ext. 2 or your Account Manager for additional questions.
If you're uploading spreadsheets by standard data integration, follow the steps below to complete your incomplete visits and upload your data.
11. Review EHR charts or patient records for the patient IDs and DOS listed in your spreadsheet. Determine if the patient data qualifies for Met Performance, Not Met Performance, or Excluded.
12. Add a column to the end of the spreadsheet and enter the numerator code for each patient ID and DOS. Numerator codes are available in each measure's description. View a full list of measures for more information.
- Some measures require multiple numerator codes. For those measures, add additional columns for the required number of numerator codes. The example below uses numerator codes for Measure 226. If you're unsure about the correct numerator codes, contact Customer Support.
13. Upload your spreadsheet to the Data Integration page in MIPSpro. Click Choose a file or drag the file into the upload box.
14. Keep the default options selected and click Continue.
15. Make sure the title of each drop-down matches the title of the column heading underneath. You can also make changes by selecting the correct title from the drop-down to match the title of the column heading. Map the numerator codes to Codes.
16. Map additional codes to the applicable title in the dropdown menu. Select Ignore to ignore the data in that column.
17. Click Complete Upload Process.
18. Review your performance. You should see an increase in Complete instances on the Quality Performance page.
This article was updated Dec. 6, 2024.