Medisolv Blog 2024 QPP Requirements

2024 QPP Requirements

2024 QPP Requirements

The Quality Payment Program has undergone some major changes over the last several years and CMS has signaled that they intend to further modify the program in the years to come. It's hard to keep all the requirements straight. In this article, we will cover the major themes that came out of the recent final ruling, review the base requirements for all participants and then review the individual requirements according to a clinician's participation status.

Major Theme Changes

There are three major themes to the changes CMS unfolded as a part of the 2024 PFS Proposed Rule.

Theme 1: MSSP ACOs must start reporting using eCQMs, CQMs, or Medicare CQMs. CMS did not extend the deadline for transitioning away from CMS Web Interface measures. That means by 2025, everyone must report Quality measures as either eCQMs, CQMs, or Medicare CQMs.

Also see: eCQM vs CQM vs Web Interface: Understanding the Difference

Theme 2: Subgroup reporting by specialty type is here. CMS expanded their reporting framework called MIPS Value Pathways (MVPs). MVPs include measures that are for specific specialty groups (like rheumatologists). CMS added five more MVPs, bringing the total to 16 different MVPs a group could use to report in 2024. Full sub-group reporting is optional until 2026, when it becomes mandatory (if you choose to report this framework). 

Also see: The 2024 MVP Reporting Bundle

Theme 3: The end of Traditional MIPS is hovering like a specter above us. CMS didn't commit to it, but they haven’t officially backed off their statement that says they will retire the Traditional MIPS reporting framework at the end of 2027, which would mean everyone must report under the MVP reporting framework (subgroup reporting by specialty type required) or be involved with an APM Entity (such as an ACO) and report through the APM Performance Pathway (APP) framework.

Let’s dive into the details.

Participation Eligibility

CMS puts Eligible Clinicians into one or more categories.

To find out your participation framework, you must check your eligibility on the QPP website.

  • Not eligible
    • Clear enough.
  • MIPS Eligible Clinician Individual
    • As an individual clinician, you are required to report to MIPS.
  • MIPS Eligible Clinician Group
    • As an eligible clinician, you are required to report to MIPS, and you are able to report as part of a group. Groups are made up of clinicians who all bill with the same Tax ID (TIN).
  • MIPS Eligible Clinician Virtual Group
    • As an eligible clinician, you are required to report to MIPS, and you are able to report as part of a virtual group. Virtual groups must be comprised of 10 or fewer Eligible Clinicians and, as a group, exceed the low-volume threshold.
  • Qualifying APM Participant (QP)
    • This clinician is a part of an Advanced APM Entity and therefore does not have to report to MIPS and automatically receives a +5% payment.
  • MIPS APM Participant
    • This clinician is part of an APM Entity, but it is not an Advanced APM, therefore they still must submit data for MIPS.

APM Entities will be referenced throughout.

The CMS participation statuses apply to the NPI associated with the provider. This eBook also references APM Entities. An APM Entity is responsible for reporting to this program on behalf of their participants.

  • Advanced APM Entity
    • An organization that takes on some form of financial risk. These organizations do not have to report to MIPS.
  • Other APM Entity
    • Those organizations not designated as advanced. ACOs make up a good portion of these types of organizations.

Reporting Frameworks

Understanding the Frameworks

Once you know your participation status, you will understand which framework you can use for submission. There are three QPP frameworks in 2024:

Traditional MIPS Framework

This is the usual MIPS framework made up of four categories and a composite score.

APM Performance Pathway (APP) Framework

The APP Framework is available to MIPS APM Entities and required for ACOs if they are part of MSSP.

MVP Framework

The MVP framework focuses on sub-group reporting by specialty type – applicable specialty measures designed for specialists. This reporting framework will eventually replace Traditional MIPS.

Here is a matrix of which framework you can report to, based on your status.

QPP-Reporting-Framework-Matrix

Each framework has slightly different requirements and different category weights.

Collection Types

Collection types are the way you report the data to CMS. You can think of them like measures. There are six collection types in 2024.

  1. eCQMs (Electronic Clinical Quality Measures)
  2. MIPS CQMs
  3. QCDR measures (Qualified Clinical Data Registry)
  4. Medicare Part B Claims measures
  5. CAHPS for MIPS survey
  6. CMS Web Interface measures (available for MSSP ACOs only)

As I mentioned before, CMS Web Interface is going away in 2025, so if this is the primary way you submitted your measures before, you need to figure out a new collection type soon.

Which collection type you can submit depends upon your participation status.

Now we are ready to review the requirements for each framework.

Learn how Medisolv helps hospitals navigate QPP changes in 2024

Check out our QPP page

 

2024 Quality Requirements

Traditional MIPS Framework

Traditional MIPS Framework: Quality Category

Category weight: 30% of total MIPS score

Performance Period: 365 days

Requirements

  • Submit 6 measures one of which is an outcome measure or high priority measure
  • Report data for at least 75% of patients who qualify for a measure
  • You may use a combo of collection types (listed below)
  • Four administrative quality claims measures are calculated automatically

Measure List

  • Quality Measures
  • Claims Measures
    1. Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Eligible Groups. 
    2. Risk-standardized Complication Rate (RSCR) following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) for MIPS
    3. Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions
    4. Risk-Standardized Acute Unplanned Cardiovascular-Related Admission Rates for Patients with Heart Failure for the Merit-based Incentive Payment System

Available Collection Types

  1. eCQMs
  2. MIPS CQMs
  3. QCDR measures
  4. Administrative claims quality measures*
  5. CAHPS for MIPS survey measures
  6. Medicare CQMs**

*Only small practices may submit quality measures using claims
**Available for MSSP ACOs

Other Considerations

Submitting the CAHPS for MIPS Survey will count as reporting one high priority measure. Select five other Quality measures to report, including an outcome measure if available.

There are no bonus points awarded for reporting additional outcome and high priority measures beyond the required one.

If you submit a new quality measure, there is 7-point minimum score awarded for submission in the measure’s first year and a 5-point minimum score awarded in its second year.

There is no floor for any measures submitted (with a benchmark). There used to be a minimum of 3-points, but that was removed in 2023.

Data Completeness Requirements

If a measure doesn’t meet the 75% data completeness threshold, the measure will earn 0 points in 2024.

Case Minimum

If a measure doesn’t meet case minimum requirements, the measure will earn 0 points in 2024.

APP Framework

APP Framework: Quality Category

Category weight: 50% of total score

Performance Period: 365 days

Requirements

Option 1

  • Submit 3 eCQMs/CQMs or Medicare CQMs
  • Meet data completeness requirements
    • You may use a combo of collection types (eCQMs, CQMs, or Medicare CQMs)
  • Two administrative quality claims measures are calculated automatically
  • CAHPS for MIPS survey

Option 2

  • Submit 10 CMS Web Interface Measures
  • Report data for 100% of assigned Medicare beneficiaries identified by CMS (248 cases)
  • Two administrative quality claims measures are calculated automatically
  • CAHPS for MIPS survey

ACOs may do both.
Highest score will be assigned to the ACO when multiple scores are available.

Measure List

  • Quality Measures (Option 1)
    • eCQMs/CQMs
      1. Quality ID: 001 Diabetes: Hemoglobin A1c (HbA1c) Poor Control
      2. Quality ID: 134 Preventive Care and Screening
      3. Quality ID: 236 Controlling High Blood Pressure
  • Quality Measures (Option 2) 
    • CMS Web Interface Measures
      1. Quality ID: 001 Diabetes: Hemoglobin A1c (HbA1c) Poor Control
      2. Quality ID: 134 Preventive Care and Screening
      3. Quality ID: 236 Controlling High Blood Pressure
      4. Quality ID: 318 Falls: Screening for Future Fall Risk
      5. Quality ID: 110 Preventive Care and Screening: Influenza Immunization
      6. Quality ID: 226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
      7. Quality ID: 113 Colorectal Cancer Screening
      8. Quality ID: 112 Breast Cancer Screening
      9. Quality ID: 438 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
      10. Quality ID: 370 Depression Remission at Twelve Months
  • Claims Measures
    1. Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Eligible Groups. 
    2. Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions
  • CAHPS for MIPS Survey measure

Other Considerations

  • CMS will still retire CMS Web Interface measures in 2025.
  • To help ACOs who are struggling with the transition, CMS finalized a new collection type called Medicare CQMs.
  • ACOs may now choose to submit eCQMs, CQMs, and/or Medicare CQMs.
  • You may choose to submit different collection types for one submission.

Data Completeness Requirements

If an eCQM or CQM does not meet the 75% data completeness threshold, the measure will earn 0 points in 2024.

MVP Framework

MVP Framework: Quality Category

Category weight: 30% of total score

Performance Period: 365 days

Requirements

  • Register for one or more of the 16 available MVPs between April 1-November 30, 2024
  • Submit 4 quality measures within the specific MVP (for each MVP) one must be an outcome measure or high priority measure
  • Report data for at least 75% of patients who qualify for a measure
  • You may use a combo of collection types

Measure List

Each measure list is specific to the particular MVP.  Download specific measure lists here.

Available Collection Types

  1. eCQMs (Electronic Clinical Quality Measures)
  2. MIPS CQMs
  3. QCDR measures (Qualified Clinical Data Registry)
  4. Administrative claims quality measures*
  5. CAHPS for MIPS survey measures
  6. Medicare CQMs**

*Only small practices may submit quality measures using claims
**Available for MSSP ACOs

Other Considerations

  • There are no bonus points awarded for reporting additional outcome and high priority measures beyond the required one.
  • If you submit a new quality measure, there is 7-point minimum score awarded for submission in the measure’s first year and a 5-point minimum score awarded in its second year.
  • There is no floor for any measures submitted (with a benchmark). There used to be a minimum of 3-points.

Case Minimum

If a measure does not meet case minimum requirements, the measure will earn 0 points in 2024.

2024 Promoting Interoperability Requirements

Traditional MIPS Framework

Traditional MIPS Framework: PI Category

Category weight: 25% of total MIPS score

Performance Period: 180 days

Requirements

  • Submit the required measures (measure list below)
  • Attest to these two measures: Prevention of Information Blocking and ONC Direct Review
  • Collect your data in EHR technology certified to the 2015 Edition or 2015 Cures Edition Update, or a combination of both
  • Provide your EHR’s CMS Identification code from the Certified Health IT Product List (CHPL)
  • Conduct or review a security risk analysis on your CEHRT functionality on an annual basis
  • Attest to conducting an annual assessment of the Safety Assurance Factors for EHR Resilience Guides (SAFER Guides)

Measure List

Promoting Interoperability Measures

  1.  e-Prescribing
  2. Query of Prescription Drug Monitoring Program (PDMP) 
  3.  Sending Health Information AND
  4. Receiving and Reconciling Health Information OR
  5. HIE Bi-Directional Exchange OR
  6. Enable Exchange Under TEFCA
  7. Provide Patients Electronic Access to Health Information
  8. Electronic Case Reporting
  9. Immunization Registry
  10. Public Health Registry
  11. Syndromic Surveillance
  12. Clinical Data Registry

Reweighting

Public Health and Clinical Data Exchange Objective has two Active Engagement options that must be completed for each associated measure:

  • Option 1: Pre-production and Validation
  • Option 2: Validated Data Production

Clinicians are required to report level of engagement for EACH measure and beginning in 2024 must transition from option 1 to option 2 after one year.

CMS is discontinuing automatic re-weighting for the following clinician types:

  • Physical therapist
  • Occupational therapist
  • Qualified speech – language pathologist
  • Clinical psychologist
  • Registered dietitians or nutrition professionals

CMS will continue to automatically assign a weight of zero to this category for:

  • Clinical social workers

CMS will continue to automatically reweight:

  • Small practices
  • Hospital-based and ambulatory surgical center-based clinicians

APM Entity

This year an APM Entity may submit Promoting Interoperability on behalf of the individual clinicians and groups they cover.

 

APP Framework

APP Framework: PI Category

Category weight: 30% of total score

Performance Period: 180 days

Requirements

Submit the required measures (measure list below)

  • Attest to these two measures: Prevention of Information Blocking and ONC Direct Review
  • Collect your data in EHR technology certified to the 2015 Edition or 2015 Cures Edition Update, or a combination of both
  • Provide your EHR’s CMS Identification code from the Certified Health IT Product List (CHPL)
  • Conduct or review a security risk analysis on your CEHRT functionality on an annual basis
  • Attest to conducting an annual assessment of the Safety Assurance Factors for EHR Resilience Guides (SAFER Guides)

Measure List

Promoting Interoperability Measures

  1. E-Prescribing
  2. Query PDMP
  3. Sending Health Information AND
  4. Receiving and Recording Health Information OR
  5. HIE Bi-Directional Exchange OR
  6. Enable Exchange under TEFCA
  7. Provide Patients Electronic Access to Health Information
  8. Electronic Case Reporting
  9. Immunization Registry
  10. Public Health Registry
  11. Syndromic Surveillance
  12. Clinical Data Registry

Other Considerations

You must submit the PI Category:

  • At an aggregate level on behalf of 100% of your Eligible Clinicians
    OR
  • 100% of your Eligible Clinicians may submit as an individual or part of a group submission separately.

By 2025 ACOs must have all their practices off of paper and on Certified EHR Technology (CEHRT).

MVP Framework

MVP Framework: PI Category

Category weight: 25% of total score

Performance Period: 180 days

Requirements

Submit the required measures (measure list below)

  • Attest to these two measures: Prevention of Information Blocking and ONC Direct Review
  • Collect your data using an EHR technology certified by ONC to meet the 2015 Cures Update Certification
  • Provide your EHR’s CMS Identification code from the Certified Health IT Product List (CHPL)
  • Conduct or review a security risk analysis on your CEHRT functionality on an annual basis
  • Attest to conducting an annual assessment of the Safety Assurance Factors for EHR Resilience Guides (SAFER Guides)

Measure List

Promoting Interoperability Measures

  1.  e-Prescribing
  2. Query of Prescription Drug Monitoring Program (PDMP) 
  3.  Sending Health Information AND
  4. Receiving and Reconciling Health Information OR
  5. HIE Bi-Directional Exchange OR
  6. Enable Exchange Under TEFCA
  7. Provide Patients Electronic Access to Health Information
  8. Electronic Case Reporting
  9. Immunization Registry
  10. Public Health Registry
  11. Syndromic Surveillance
  12. Clinical Data Registry

Reweighting

Public Health and Clinical Data Exchange Objective has two Active Engagement options that must be completed for each associated measure:

  • Option 1: Pre-production and Validation
  • Option 2: Validated Data Production

Clinicians are required to report level of engagement for EACH measure and beginning in 2024 must transition from option 1 to option 2 after one year.

CMS is discontinuing automatic re-weighting for the following clinician types:

  • Physical therapist
  • Occupational therapist
  • Qualified speech – language pathologist
  • Clinical psychologist
  • Registered dietitians or nutrition professionals

CMS will continue to automatically assign a weight of zero to this category for:

  • Clinical social workers

Promoting Interoperability Measures

Query of Prescription Drug Monitoring Program (PDMP)

  • Exclusion modified to the following: “Does not electronically prescribe any Schedule II opioids or Schedule III or IV drugs during the performance period”

Safety Assurance Factors for EHR Resilience (SAFER) Guides

  • Requires a “yes” attestation response beginning with 2024

2024 Improvement Activities Requirements

Traditional MIPS Framework

Traditional MIPS Framework: IA Category

Category weight: 15% of total MIPS score

Performance Period: 90 days

Requirements

  • Submit one of the following combinations of activities
    • 2 high-weighted activities
    • 1 high-weighted activity and 2 medium-weighted activities
    • 4 medium-weighted activities

Measure List

Improvement Activity Measures

Other Considerations

If you are submitting as a group at least 50% of your group’s clinicians must attest to completing the same improvement activity for 90 consecutive days. The activity may be completed anytime within the calendar year so long as each clinician attesting completes the activity for 90 consecutive days.

Patient-Centered Medical Homes

If you are a Patient-Centered Medical Home and more than 50% of your practices are recognized as a PCMH, you automatically receive full credit for this category.

APP Framework

APP Framework: IA Category

Category weight: 20% of total score

Requirements

All APM Entities reporting through the APP Framework will be automatically assigned a score of 100% which is applied to all Eligible Clinicians reporting through their APM Entity.

MVP Framework

MVP Framework: IA Category

Category weight: 15% of total score

Performance Period: 90 days

Requirements

  • Submit one of the following combinations of activities
    • 1 high-weighted activities
    • 2 medium-weighted activities

Measure List

Improvement Activity Measures

Patient-Centered Medical Homes

If you are a Patient-Centered Medical Home and more than 50% of your practices are recognized as a PCMH, you automatically receive full credit for this category.

 

2024 Cost Requirements 

Traditional MIPS Program

Traditional MIPS Framework: Cost Category

Category weight: 30% of total MIPS score

Performance Period: 365 days

Requirements

  • CMS will evaluate your performance on 29 claims measures.

Measure List

Cost Measures

Other Considerations

If you don’t meet the established case minimum for any of the 29 measures to be scored, the cost performance category will receive zero weight when calculating your final score and the 30% will be distributed to another performance category (or categories).

APP Framework

Not applicable.

MVP Framework

MVP Framework: Cost Category

Category weight: 30% of total score

Performance Period: 365 days

Requirements

  • CMS will evaluate your performance on cost measures via claims data.
  • You will only be scored on the Cost measure relevant to your specific MVP.

Measure List

2024 Population Health Requirements

Traditional MIPS Framework

Not applicable.

APP Framework

 Not applicable.

MVP Framework

MVP Framework: Population Health Category

Category weight: Combined with your Quality Score 

Performance Period: 365 days

Requirements

Select 1 of the 2 population health measures available at the time of MVP registration

  • Q479: Hospital-Wide, 30-day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups
  • Q484: Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions

Other Considerations

  • CMS calculates performance based on administrative claims data.
  • Score is calculated and included in the Quality performance category.

2024 Bonus Points

There are many opportunities to get bonus points within the MIPS program.

Improvement Bonus: Up To 10 Points

Clinicians will be rewarded if they demonstrate any improvement to their 2023 Quality score over the prior year (pending there is enough data for comparison). New Clinicians will be rewarded up to 1 additional point for improvement to their Cost performance scores.

Complex Patient Bonus: 5 Points

For clinicians who work with patients that have more complex cases, CMS will award up to 5 points to account for the additional complexity of treating their patient population.

Small Practice Bonus: 6 Points

An additional 6 bonus points will be added to the numerator of the Quality category for anyone qualifying as a small practice.

 

2024 Score Threshold Reimbursement

Applicable to MIPS and MVP Reporting Frameworks

To avoid a -9% penalty, you must score at least 75 points.

 ScoreDistributionGraph

 

0-18.75 Points

If your score is between 0 and 18.75 points, you will lose -9% from your Medicare fee schedule (in red above).

18.76-74.99 Points

If your score is between 18.76 and 74.99 points, you will receive a reduction to your Medicare fee schedule between -8.99% and 0%

75 -100 Points

75 points is the performance threshold. CMS will take the funds of those who did not meet the threshold (in red) and distribute them among those who did meet the threshold (in green). Anyone whose MIPS score is between 75 and 100 points will receive some portion of those funds – up to a 9% increase to your Medicare fee schedule.

Note: There is no longer an Exceptional Performance bonus


APP Reporting Framework - MSSP ACOs

Shared Savings

To get the maximum shared savings for your ACO you must:

Report ALL measures in the APP measure set
AND
Achieve the Quality Performance Standard

CMS has implemented a sliding scale to give ACOs some percentage of the Shared Savings (not max) if they don’t meet the quality performance standards but do achieve a quality performance score equivalent to or higher than the 10th percentile of the performance benchmark on at least one of the four outcome measures.


Maximize Your Shared Savings

Quality Performance Standard

  1. Report eCQMs/CQMs
  2. Achieve a score = > 10th percentile on 1 outcome measure
  3. Achieve a score = > 40th percentile on at least 1 of the remaining measure

OR

Health Equity-Adjusted score of => 40th percentile across ALL quality performance scores 

Quality Performance Standard

CMS will calculate 2024 and 2025 benchmarks for the Medicare CQMs based on performance period benchmarks. They will transition to historical benchmarks in 2026 and subsequent years.

This means that ACOs will not know the Medicare CQM benchmarks during the performance period.

CMS is NOT extending the eCQM/MIPS CQM reporting incentive to Medicare CQMs.

CMS finalized the use of historical data to establish the 40th percentile MIPS Quality performance category score used for the quality performance standard.

That means you would know what the Quality Performance Standard percentile is BEFORE the performance year starts.

40th Percentile MIPS Quality Performance Category Scores Used in the Calculation of the PY 2024 Historical MIPS Quality Performance Category Score

Performance Year

40th Percentile of the MIPS Quality Performance Category Score

2020

75.59^

2021

77.83^

2022

77.73^

2023

Skipped due to 1-year lag

2024

77.05

^ PY 2020 through PY 2022 40th percentile scores are based on performance period data

 

Important Dates

January 1, 2024

The start date to track 365 days of Quality and Cost category measures.

April 1, 2024

Registration opens for CMS Web Interface, CAHPS for MIPS Survey, and MVP selection.

July 4, 2024                   

The last day to start measures in the Promoting Interoperability category to meet the minimum of 180 continuous days.

October 2, 2024

The last day to start Improvement Activities to meet the minimum requirement of 90 continuous days.

November 30, 2024

Last day to register for an MVP.

March 31, 2025

The last day to submit all of your performance data.

 

Medisolv's QPP Package 

Medisolv Can Help

This is a big year for Quality. Medisolv can help you along the way. Along with award-winning software you receive a dedicated Medisolv Clinical Quality Advisor that helps you with all of your technical and clinical needs with no time restraints or extra costs.
 
We consistently hear from our clients that the biggest differentiator between Medisolv and other vendors is the level of one-on-one support. Especially if you use an EHR vendor right now, you’ll notice a huge difference.

  • We help troubleshoot technical and clinical issues to improve your measures.
  • We keep you on track for your submission deadlines and ensure you don’t miss critical dates
  • We help you select and set up measures that make sense based on your hospital’s situation.
  • You receive one advisor that you can call anytime with questions or concerns.

Contact us today.

 

 
 
 

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