Merit-based Incentive Payment System: 2021 Quality Measures
Beginning in 2017, the Merit-based Incentive Payment System (MIPS) combines previous CMS pay for performance programs including PQRS, the Value Modifier and Meaningful Use (rebranded as Advancing Care Information - ACI) with the addition of a category for Clinical Practice Improvement Activities (CPIA). A group or individual MIPS eligible provider is scored in each of these areas based on performance, and an aggregate score (1-100) is generated. That aggregate score will be compared to national benchmarks determining whether a positive or negative adjustment is applied to future Medicare reimbursement (2022 reimbursement adjustment for 2021 performance year).
For the 2021 Quality component, TRA will be submitting the measures below with the assistance of Zotec coders. A few additional measures may also be available through the ACR Qualified Clinical Data Registry (QCDR). A brief description of each follows including links to more detailed documentation in pdf format. Performance on these 9 metrics will be calculated and submitted to CMS by Zotec. If/when new metrics come on-line, they will be added to this document.
MIPS Quality Measures for 2021:
Measure 145:
Exposure dose or time reported for fluoroscopy
Measure 146:
Inappropriate use of “probably benign” category on screening mammography
Measure 147:
Correlation with existing imaging studies for patients undergoing bone
scintigraphy
Measure 195:
Stenosis measurement in carotid imaging reports
Measure 225:
Reminder system for screening mammograms
Measure 364: Appropriate Follow-up for Incidental Pulmonary Nodules
Measure 405: Appropriate Follow-up for Incidental Abdominal Lesions (UAOM EXAMS ONLY)
Measure 406: Appropriate Follow-up for Incidental Thyroid Nodules
Measure 436:
Radiation consideration for adult CT: Utilization of dose lowering techniques
Measure 145: Exposure dose or time reported
for fluoroscopy
Reports for
procedures using fluoroscopy should include radiation exposure indices OR the
total fluoroscopy time AND number of fluoroscopic images.
If using a
measure of radiation exposure, the report should include which specific dose
metric is being documented. The accepted exposure metrics include:
1.
Skin dose mapping
2.
Peak skin dose (PSD)
3.
Reference air kerma (Ka,r)
4.
Kerma area product (Pka) or dose area product (DAP)
Note: For
interventional or other procedures where “runs” are acquired, the fluoroscopy
time and number of runs acquired can be reported instead of counting individual
images.
Note: Images
acquired through “last image hold” do not need to be included when counting the
number of fluoroscopic images as they do not result in additional radiation
exposure.
Click
here for more information on measure 145.
Measure 146: Inappropriate use of “probably
benign” category on screening mammography
For this
measure, the numerator is the number of screening mammograms reported as BIRADS
3 – Probably Benign, and the denominator is the total number of screening
mammograms. This is an inverse measure where a lower calculated performance
rate indicates better clinical care.
Click
here for more information on measure 146.
Measure 147: Correlation with existing
imaging studies for patients undergoing bone scintigraphy
This metric
evaluates the percentage of reports for patients undergoing bone scintigraphy
that include documentation of correlation with relevant comparison studies
(X-ray, CT, MR, etc.).
Note: There
is an exception to this metric for patients without comparison imaging. In
these cases, documentation should include statements such as “no existing
relevant imaging study available” or “patient has no previous relevant imaging
study”.
Click
here for more information on measure 147.
Measure 195: Stenosis measurement in
carotid imaging reports
This metric
assesses the percentage of reports for carotid imaging studies (neck MRA, neck
CTA, carotid duplex ultrasound, carotid angiogram) performed that include direct
or indirect reference to measurements of distal internal carotid diameter as
the denominator for stenosis measurement.
For CTA, MRA
or angiography, the report should include an estimate of stenosis based on the
NASCET methodology (stenosis calculated with reference to the lumen distal to
the stenosis).
For duplex
imaging studies the reference is indirect. In Doppler ultrasound, the degree of
stenosis can be estimated using Doppler parameter of the peak systolic velocity
(PSV) of the internal carotid artery (ICA), with concordance of the degree of
narrowing of the ICA lumen. Additional Doppler parameters of ICA-to-common
carotid artery (CCA) PSV ratio and ICA end-diastolic velocity (EDV) can be used
when degree of stenosis is uncertain from ICA PSV.
Examples of
sufficient documentation include:
-“Severe left ICA stenosis of 70-80% by NASCET criteria” or
-“Severe left ICA stenosis of 70-80% by criteria similar to NASCET”
or
-“70%
stenosis derived by comparing the narrowest segment with the distal luminal
diameter as related to the reported measure of arterial narrowing” or
-“Severe stenosis of 70-80% - validated velocity
measurements with angiographic measurements, velocity criteria are extrapolated
from diameter data as defined by the
Society of Radiologists in Ultrasound Consensus Conference Radiology 2003;
229;340-346”.
Click
here for more information on measure 195.
Measure 225: Reminder system for screening
mammograms
All
mammography systems within the practice include automated reminder systems.
Performance data for this measure is submitted through an attestation process
whereby we indicate to Zotec that all screening
mammograms meet the requirements for this measure and they submit that as peformance data to the registry. No specific changes are
required to your reports.
Click
here for more information on measure 225.
Measure 364: Appropriate Follow-up for Incidental Pulmonary Nodules
Performance is met if there is an incidental pulmonary nodule and the final report includes follow-up recommendations documented according to recommended guidelines based nodule size and patient risk factors. If the guideline recommendations or a medical reason for follow-up are not documented, the report will be sent through the RFI for additional information. New for 2020, CMS is requiring that reports cite the specific consensus guideline utilized for the recommendation. Zotec has indicated that the journal article citation currently included in our standard macros will meet requirements.
Click
here for more information on measure 364.
Measure 405: Appropriate Follow-up for Incidental Abdominal Lesions (UAOM EXAMS ONLY)
This measure is directed at benign incidental lesions of the kidney or adrenals, specifically:
• Cysticrenal lesion that is simple appearing* (Bosniak I or II)
• Adrenal lesion less than or equal to 1.0 cm
• Adrenal lesion greater than 1.0 cm but less than or equal to 4.0 cm classified as likely benign by unenhanced CT or washout protocol CT, or MRI with in- and opposed-phase sequences or other equivalent institutional imaging protocols
New for 2020, reports mentioning these benign lesions will require specific mention that “no follow-up imaging is required”. Reports will be pushed back through RFI if the recommendation for “no imaging follow-up” for one of these benign lesions is not included in the impression.
Click
here for more information on measure 405.
Measure 406: Appropriate Follow-up for Incidental Thyroid Nodules
This measure is directed at small (< 1.0 cm) incidental thyroid nodules on CT/MR. This is also an inverse measure – lower score = better performance. The denominator is all incidental thyroid nodules < 1.0 cm. The numerator is final reports with follow-up imaging recommended for these incidental small thyroid nodules (which generally don’t require follow-up). Reports will be pushed back through RFI if follow-up is recommended for one of these small lesions and a medical reason is not provided.
Click
here for more information on measure 406.
Measure 436: Radiation consideration for
adult CT: Utilization of dose lowering techniques
This metric
assesses the percentage of CT reports on patients age 18 and older containing
documentation of one or more of the following dose reduction techniques:
Automated exposure control
Adjustment of mA and/or kV
according to patient size
Use of iterative reconstruction
technique
To satisfy
the measure, the following statement should be added to the technique section
of all* adult CT reports:
In
accordance with CT policies/protocols and the ALARA principal, radiation dose
reduction techniques (such as automated exposure control, adjustment of mA/kV
according to patient size and/or iterative reconstruction technique) were
utilized for this examination.
Note: The
above statement can be applied to all* CT reports, regardless of whether or not
automated exposure control or iterative reconstruction was utilized. After
discussion with the ACR, we arrived at the shared conclusion that if CT
protocols/policies/procedures encourage technologists to adjust CT dose
parameters (mA/kV) based on patient size, performance for the metric is
satisfied regardless of whether AEC or IR techniques were utilized and
regardless of whether dose parameters are/are not adjusted for every individual
exam.
*Note: The
exception to the rule above is radiation therapy planning CTs where automated
exposure control was not utilized. The radiation oncology techs do not follow
TRA-MINW protocols so we cannot rely on the “adjustment of mA/kV according to
patient size” option discussed above.
Click
here for more information on measure 436.