Quality Reports

Let’s review the three reports that will allow you to track your Quality measure performance including Performance Rate and benchmark Decile Score. 

Accessing Quality Reports

Let’s explore the available reporting options.

  1. Log into the MIPS portal: https://webpt.mips.healthmonix.com.  
  2. Click the Admin tab at the top of the page.                                         
  3. Then, select Dashboard next to your Practice name. 
  4. Click Continue in the Quality section.
  5. Select Quality Performance in the top-right corner. 
  6. There are three reports that make up the Quality Reports section: CMS Performance, NPI Analysis, and Quality Points. We’ll review each of these reports below.

CMS Performance

The CMS Performance page allows you to view the Performance Rate for each measure, for all reporting therapists within the TIN. Sort the report by clicking on a column header; click once to sort by highest value first, and twice to sort by lowest value first.

Report Fields

  • Measures: Each of the measures you selected during setup will appear in this column.
  • Total Instances: The total number of patients and visits that were found to be eligible, or partially eligible, for reporting and scoring of the measure.
  • Complete Instances: The total number of patients and visits that had complete information to be eligible for reporting and scoring of the measure.
  • Met: The total number of patients and visits that “Met Performance” for the Measure.
  • Exclusions: The total number of patients and visits that will be excluded from scoring.
  • Not Met: The total number of patients and visits that did not meet performance for the measure.
  • Performance Rate: The percentage is calculated by comparing the patients and visits that met performance, by the total number of patients or visits that were eligible for the measure’s reporting and scoring (all patients and visits who met performance plus all patients and visits who did not meet performance).

Rate vs Decile

This report allows you to toggle between viewing your Rate and Decile. Your measure score relies not only on meeting the performance requirements but also on how you perform against the measure’s benchmark if it has one. Each measure has deciles that relate to points received (if the expected performance rate is met). Toggling on the Decile view shows you a heat map of your ranking. 

Deciles and Scoring

While measure performance is quantified in percentages, each benchmark has deciles, with points awarded by the decile achieved. Providers who earn a performance score in the first or second decile will receive 3 points. Providers who are in the 3rd decile will receive somewhere between 3 and 3.9 points depending on their exact position in the decile. Providers in higher deciles will receive a corresponding number of points. Remember, the decile ranges for each measure will be different, so achieving an 85% on one measure may equate to the 8th decile, but 85% on another measure could land you in the 3rd decile. 

Example

  • Measure ‘X’ Performance Rate = 83%
  • Decile 6 = 78% - 84%
  • Decile 7 = 85% - 93%

Using the provided information, the rate would fall into the 6th decile. The number of points you expect to be awarded would be between 6 and 6.9 points, according to the above table.

Topped Out Measure Deciles

You’ll want to pay particular attention to topped out measures. It is extremely difficult to score above the 3rd decile without having 100% met performance for a measure. Let’s take a quick look at the deciles for topped out Measure 182. You’ll note that you can only score 10 points if you reach 100% performance met.

Measures without Deciles

Remember, measures without benchmarks will not have deciles. All non-benchmarked measures will receive a maximum of 3 points.           

What does it mean if I have more Total Instances than Complete Instances?

If you notice a large disparity between Total Instances and Complete Instances, you may need to verify that your therapists are completing the measure correctly and reporting the right code. You can click on the number below Total Instances to open the Visits page. You can then use the filters on the left-hand side to only show incomplete measures and the related patient ID.

Drilling Down into Visit/Patient Data

  1. Clicking on any of the Instances numbers within the report will open a list of all Visits related to the selected number.              
  2. On the Visits page, the number associated with the Patient column is a unique identifier in the WebPT EMR. This ensures you can easily locate a patient if you need to make an update to their measure documentation.             
  3. To locate the patient, log into the clinic associated with the patient and paste this into your browser bar https://app.webpt.com/patientChart.php?ID= then include the patient ID number from the report at the end. So for the example above, the complete URL should be https://app.webpt.com/patientChart.php?ID=131                                                                                     

NPI Analysis

This report allows you to see the Performance Rate and Decile for each reporting individual. This report functions primarily the same as the CMS Performance page, including the ability to view individual performance by Rate or Decile. Let’s take a quick look at some of the key differences that allow you to view individual results. 

  • There is a Select NPI drop-down at the top of the page that will allow you to narrow the entire page view by the selected user.                            
  • You can use the plus icon next to each measure to view individual performance.             
  • You can also use the Expand All Measures checkbox to quickly view all individual scores by measure. This requires the system to take action on each measure, so it may take a few moments to generate.

Quality Points

This section allows you to view your Actual and Predicted Quality Points. Remember, the MIPS Portal will automatically select your top 6 measures for you. You’ll have the opportunity to verify and/or change these measures before submitting to CMS when the reporting period ends. 

  • The Actual view shows you the points you would get if you submitted to CMS today. Actual points factor in all the reporting rules from CMS. This includes ensuring that measures have at least 20 instances and at least 60 percent of eligible instances are reported.
  • The Predicted points assume that reporting completion rules are satisfied. By applying this assumption the predicted view anticipates the points you will receive once the ‘60 percent threshold’ and ‘20 eligible instances per measure’ rules are satisfied. These scores are calculated based on your decile achievement.

We’ll start with the Predicted Quality Points section.

Predicted Quality Points

This report provides a quick view into how your performance compares to the measure benchmarks, and ultimately, what you can expect to score at the end of the performance period. This simply extrapolates your current performance. 

One key thing to note here is the Improvement Bonus value. This only applies to clinicians who reported in the prior program year. 

Measure Tiles

Your top 6 measures appear in a tiled view. There are three key things to be aware of, so let’s take a quick look. 

  1. This decile number represents your performance against the benchmark. Remember, each decile is roughly equivalent to the number of points received. 
  2. This prediction is based solely on your decile and any bonus point potential.
  3. Some measures may have this dashed element. Explore the measure table view below to discover what this means. 

Measure Table

You’ll be able to review any measures that deviate from the standard. Here, you’ll notice that we have not selected an outcome measure, so the portal is warning us that we’ll miss out on an associated bonus point. You’ll also note that #226 has highlighted the scoring for Predicted and Total Possible Points. Hovering over these fields reveal that this measure does not have a benchmark, so the maximum achievable score is 3.

Actual Quality Points

This report has the same functionality as the Predicted Quality Points report. Remember, the key difference between the data in these reports is that the Actual Quality Points score accounts for your progress against the CMS requirements of 20 completed instances and a 60% completion threshold.

Simply click the Actual toggle at the top to switch to this view.