In general, quality measures consist of a numerator and a denominator that permit the calculation of the percentage of a defined patient population which receives a particular process of care that is subsequently reported to CMS.
The denominator population is defined by certain ICD-10 and/or CPT Category I codes specified in the measure that are submitted by eligible professionals as part of a claim for covered services under the Medicare Physician Fee Schedule. Some measure coding specifications are adapted as needed for implementation in MIPS in agreement with the measure developer. For example, CPT codes for non-covered services such as preventive visits are not included in the denominator. If the specified denominator codes for a measure are not included in the patient's claim as submitted, then the patient does not fall into the denominator population, and the measure does not apply to that particular patient.
If the patient does fall into the denominator population, the applicable CPT Category II code (or temporary G-code, where CPT Category II codes are not yet available) that defines the numerator should be submitted. When a patient falls into the denominator population but specifications define circumstances in which a patient may be excluded from the measure's denominator population, CPT Category II code modifiers such as 1P are available to describe medical, patient, system, or other reasons for such exclusion.
To successfully report quality data for a measure under the Quality reporting program, it is necessary in all circumstances to report numerator coding (CPT Category II code and/or G-code), with or without an applicable CPT Category II code modifier. Instructions specific to each measure (available in the measure specifications) provide additional reporting information and details on what the measure is intended to accomplish.
Instructions for some measures limit the frequency of reporting necessary in certain circumstances, such as for patients with chronic illness for whom a particular process of care is provided only periodically (e.g. once per year).
The measure specifications are organized to provide the following information:
- Measure title
- Measure type
- Reporting option available
- Measure description
- Instructions on reporting including frequency, timeframes, and applicability
- Denominator definition and coding
- Numerator definition and coding
- Rationale statement for measure
- Clinical recommendations or evidence forming the basis or supporting criteria for the measure