Form CMS-10621 ACI Call for Measures Submission Form

Quality Payment Program

Advancing Care Information
Performance Category
Call for Measures Submission Form
Submission Period January 31 through June 30, 2017
for 2019 Measures
Stakeholders must use this form to propose new measures under the Advancing Care Information (ACI)
Performance Category for the Merit -based Incentive Payment System (MIPS) in 2019. The submission
deadline is June 30, 2017.
Proposals must be sent to [email protected]. Stakeholders will receive email
confirmations for their submission.

SECTION 1: STAKEHOLDER INFORMATION
Provide the following information for the individual, group or association proposing a new measure for the
Advancing Care Information Performance Category under MIPS. All required fields are indicated with an
asterisk (*). This information will be used to contact the stakeholder(s) if necessary, and apprise them of
determinations made for their proposed measure(s).
Submitter First Name*

Middle Initial

Submitter Last Name*

Credentials
(MD, DO, etc.)

Name of Organization (if applicable) *:

Address Line 1 (Street Name and Number – Not a Post Office Box or Practice Name) *
Address Line 2 (Suite, Room, etc.)
City/Town*

State (2 character code) *

Zip Code (5 digits) *

Email Address* (This is how we will communicate with you.)

1

Quality Payment Program

Business Telephone Number (include Area Code)

Extension

SECTION 2: CONSIDERATIONS WHEN PROPOSING MEASURES
CMS priorities for proposals on Advancing Care Information Performance Category measures include those
that: (1) build on the advanced use of certified EHR technology (CEHRT) using 2015 Edition Standards and
Certification Criteria to increase health information exchange and continue improving program efficiency,
effectiveness, and flexibility, (2) measure patient outcomes and emphasize patient safety and (3) support
improvement activities and quality performance categories of MIPS. Proposals submitted by June 30, 2017
will be considered for inclusion in rulemaking effective for 2019.
When preparing proposals, please consider whether the new measure:
1. Could highlight improved beneficiary health outcomes, patient engagement and safety;
2. Could improve program efficiency, effectiveness and flexibility;
3. Would contribute to improvement in patient care practices, reduce reporting burden, or includes
an emerging certified health IT functionality or capability;
4. Does not duplicate existing objectives and measures;
5. Should be considered for a Base, Performance or Bonus score;
6. Is feasible to implement; and
7. Is able to be validated by CMS.

SECTION 3: REQUIRED INFORMATION FOR MEASURE PROPOSALS
Proposals that do not provide information for every field/section will not be evaluated for consideration. Any
information/field not applicable to the measure proposal must state “N/A” or “not applicable” or the proposal
will not be considered, as the application will be judged incomplete.

2

Quality Payment Program

1. MEASURE DESCRIPTION (Provide a description of the measure to be considered and relevance to the
Advancing Care Information performance category):

Program Relevance:

2. MEASURE TYPE:
Please indicate which category your measure descriptions fits:
Patient Outcome Measure
Process Measure
Patient Safety Measure
Other (please indicate the type of measure):

3

Quality Payment Program

3. REPORTING REQUIREMENT – Yes/No Statement or Numerator and Denominator Description
Indicate whether the measure should include as a reporting requirement: 1) a yes/no statement and
exclusion criteria (if applicable) or 2) the numerator and denominator, threshold (if applicable) and exclusion
criteria (if applicable).
YES/NO STATEMENT
Exclusion Criteria:
If applicable and rationale for exclusion proposal, otherwise use N/A

OR
Denominator Language:

Numerator Language:
Threshold:
(For example: at least one (clinical action or patient) or a percentage - at least 5 percent). The clinical
action must be tied to the numerator proposed language. For example: Secure Messaging Measure: For at
least one unique patient seen by the MIPS eligible clinician during the performance period, a secure
message was sent. Include a rationale for recommendation:
At least one (ex., Patient or clinical action)
Recommended percentage (please state –for example: at least 5 percent):
Rationale:

Exclusion Criteria:
If applicable and rational for exclusion proposal; otherwise use N/A

4

Quality Payment Program

4. CEHRT FUNCTIONALITIES REQUIRED FOR PROPOSED MEASURE:
Describe CEHRT functionalities that are needed to attest successfully to this proposed measure, if applicable.
If you do not believe certain functionalities are required (such as an application programming interface, or
API) please use N/A.
Functionality type (ex. API):

N/A

5. SCORE TYPE
Please indicate the type of score your proposed measure should be considered for and rationale for selection.
Base Score
Performance Score
Bonus Score
Rationale for selection:

5

Quality Payment Program

Optional:
Additional Information, suggestions and/or comments related to the Call for Measures

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is 09381314 (Expiration date: XX/XX/XXXX). The time required to complete this information collection is estimated to average
0.5 hours per response, including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do
not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA
Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden
approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If
you have questions or concerns regarding where to submit your documents, please contact [email protected]

6