CMS-10621 - Supporting Statement B

Supporting Statement – Part B
Quality Payment Program/Merit-Based Incentive Payment System (MIPS)
CMS-10621, OMB 0938-1314
Collections of Information Employing Statistical Models
Introduction
The Merit-based Incentive Payment System (MIPS) is one of two paths for clinicians
available through the Quality Payment Program authorized by the Medicare Access and CHIP
Reauthorization Act of 2015 (MACRA). The Quality Payment Program replaced three precursor
Medicare reporting programs with a flexible system that allows clinicians to choose from two
paths that link quality to payments: the Merit-Based Incentive Payment System (MIPS) and
Advanced Alternative Payment Models (APMs). The MIPS path measures MIPS eligible
clinicians and groups on four performance categories: quality, cost, improvement activities, and
Promoting Interoperability (related to meaningful use of certified EHR technology or CEHRT).
Under the APM path, clinicians participating in certain types of APMs (Advanced APMs) may
become Qualifying APM participants (QPs) and be excluded from MIPS. QPs will receive
lump-sum APM incentive payments equal to 5 percent of their estimated aggregate payment
amounts for Medicare covered professional services in the preceding year.
The primary purpose of this collection is to generate data on a MIPS eligible clinician or
group so that CMS can assess MIPS eligible clinician performance in the four performance
categories, calculate the final score, and apply performance-based payment adjustments. We
will also use this information to provide regular performance feedback to MIPS eligible
clinicians and eligible entities. This information will also be made available to beneficiaries, as
well as to the general public, on the care compare tool hosted by the U.S. Department of Health
and Services. In addition, the data collected under this PRA will be used for research,
evaluation, and measure assessment and refinement activities.
Specifically, CMS uses the data to produce annual statistical reports that provide a
comprehensive representation of the overall experience of MIPS eligible clinicians as a whole
and subgroups of MIPS eligible clinicians. The data will also be utilized to fulfill a MACRA
requirement in which the GAO must perform a MIPS evaluation to submit to Congress by
October 1, 2021. 1 Further, CMS has processes to monitor and assess measures to ensure their
soundness and appropriateness for continued use in the MIPS. As required by the MACRA, the
ongoing measure assessment and monitoring process will be used to refine, add, and drop
measures as appropriate, as shown in the proposed changes to the measure sets discussed in the
MACRA mandates that the GAO evaluate and make recommendations regarding the final scores and the impact
of technical assistance.

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CY 2022 PFS proposed rule. Supporting Statement Part B characterizes the respondents of this
collection and any sampling used in data collection so that, when grouped/aggregated data are
presented, the inferences that can be drawn from those data are clear.
There are 26 information collections in the CY 2022 PFS proposed rule requirements and
burden estimates. The discussion in this Supporting Statement Part B focuses on the 7
information collections for which we plan to conduct statistical reporting and analyses: quality
performance category data submitted via Medicare Part B claims, eCQM, and MIPS CQM and
QCDR collection types, the quality performance category submissions for MVPs, the CMS Web
Interface, and data submitted for the Promoting Interoperability and improvement activities
performance categories.
1. Describe (including a numerical estimate) the potential respondent universe and any
sampling or other respondent selection method to be used. Data on the number of
entities (e.g., establishments, State and local government units, households, or persons)
in the universe covered by the collection and in the corresponding sample are to be
provided in tabular form for the universe as a whole and for each of the strata in the
proposed sample. Indicate expected response rates for the collection as a whole. If the
collection had been conducted previously, include the actual response rate achieved
during the last collection.
Quality Performance Category Data Submission
Potential respondent universe and response rates
We anticipate that two groups of clinicians will submit quality data under MIPS: those
who submit as MIPS eligible clinicians and other eligible clinicians who submit data voluntarily.
We estimate the potential respondent universe and response rates for MIPS eligible clinicians
and clinicians excluded from MIPS using data from the CY 2019 MIPS performance
period/2021MIPS payment year and other CMS sources. To determine which QPs should be
excluded from MIPS, we used Advanced APM payment and patient percentages from the APM
Participant List for the final snapshot date for the 2019 QP performance period. From this data,
we calculated the QP determinations as described in the Qualifying APM Participant definition
at § 414.1305 for the CY 2022 MIPS performance period/2024 MIPS payment year. Due to data
limitations, we could not identify specific clinicians who may become QPs in the CY 2022 MIPS
performance period//2024 MIPS payment year; hence, our model may underestimate or
overestimate the fraction of clinicians and allowed charges for covered professional services that
will remain subject to MIPS after the exclusions.
We assume that 100 percent of ACO APM Entities will submit quality data to CMS as
required under their models. While we do not believe there is additional reporting for ACO
APM entities, consistent with assumptions used in the CY 2020 and CY 2021 PFS final rules (84
FR 63122 and 85 FR 84972), we include all quality data voluntarily submitted by MIPS APM
participants made at the individual or TIN-level in our respondent estimates. As stated in section
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V.B.8.e.(2) of the CY 2022 PFS Proposed Rule, we assume non-ACO APM Entities will
participate through traditional MIPS and submit as an individual or group rather than as an
entity. To estimate who will be a MIPS APM participant in the CY 2022 and CY 2023 MIPS
performance periods/2024 and 2025 MIPS payment years, we used the final snapshot data from
the 2019 QP performance period. We elected to use this data source because the APM participant
list for the 2019 final snapshot can reliably be used for MIPS APM participant projections. Based
on this information, if we determine that a MIPS eligible clinician will not be scored as a MIPS
APM, then their reporting assumption is based on their reporting as a group or individual for the
CY 2019 MIPS performance period/2021 MIPS payment year.
As discussed in Supporting Statement A, we explain that we assume 809,625 MIPS
eligible clinicians will submit data as individual clinicians (both required and voluntary), or as
part of groups or APM entities in the CY 2022 MIPS performance period/2024 MIPS payment.
Included in this number, we estimate that 3,259 clinicians who exceeded at least one but not all
low-volume threshold criteria, elected to opt-in and submitted data in the CY 2019 MIPS
performance period/2021 MIPS payment year will elect to opt-in to MIPS in the CY 2022 MIPS
performance period/2024 MIPS payment year. While this is the estimated number of MIPS
eligible clinicians, the number of respondents that actually submit data varies significantly due to
differences in individual, group, virtual group, and APM entity reporting and by the requirements
and policies for each performance category.
CMS annual statistical reports about MIPS will be able to provide estimates of the
numbers and percentages of MIPS eligible clinicians submitting quality that can be generalized
to the entire population of MIPS eligible clinicians, and to relevant subpopulations (such as
eligible clinicians participating in MIPS APMs).
Sampling for quality data submission
In the CY 2022 PFS proposed rule, we are proposing to continue the 70 percent data
completeness threshold for the CY 2022 MIPS performance period/2024 MIPS payment year.
We are also proposing to increase the data completeness criteria threshold from at least 70
percent to at least 80 percent beginning with the CY 2023 MIPS performance period/2025 MIPS
payment year, in which MIPS eligible clinicians and groups submitting quality measures data on
Medicare Part B claims measures must submit data on at least 80 percent of the applicable
Medicare Part B patients seen during the CY 2023 MIPS performance period to which the
measure applies for MIPS payment year 2025. Tables 1a and 1b summarize the data
completeness criteria for the CY 2022 and 2023 MIPS performance periods/2024 and 2025
MIPS payment years.

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TABLE 1a: Summary of Data Completeness Requirements and Performance Period by
Collection Type for the 2022 and 2023 MIPS Performance Periods
Collection Type
Medicare Part B Claims
measures

Performance Period
Jan 1- Dec 31

Data Completeness
For the CY 2022 MIPS
performance period/2024 MIPS
payment year, 70 percent sample
of individual MIPS eligible
clinician’s, or group’s Medicare
Part B patients for the performance
period.
For the CY 2023 MIPS
performance period/2025 MIPS
payment year, 80 percent sample
of individual MIPS eligible
clinician’s, or group’s Medicare
Part B patients for the performance
period.

Administrative claims
measures

Jan 1- Dec 31

100 percent sample of individual
MIPS eligible clinician’s Medicare
Part B patients for the performance
period.

QCDR measures, MIPS
CQMs, and eCQMs

Jan 1- Dec 31

For the CY 2022 MIPS
performance period/2024 MIPS
payment year, 70 percent sample
of individual MIPS eligible
clinician’s, or group’s patients
across all payers for the
performance period.
For the CY 2023 MIPS
performance period/2025 MIPS
payment year, 80 percent sample
of individual MIPS eligible
clinician’s, or group’s patients
across all payers for the
performance period.

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Collection Type

Performance Period

Data Completeness

CMS Web Interface measure
(CY 2022 MIPS performance
period only)

Jan 1- Dec 31

Sampling requirements for the
group’s Medicare Part B patients:
populate data fields for the first
248 consecutively ranked and
assigned Medicare beneficiaries in
the order in which they appear in
the group’s sample for each
module/measure. If the pool of
eligible assigned beneficiaries is
less than 248, then the group
would report on 100 percent of
assigned beneficiaries.

CAHPS for MIPS survey
measure

Jan 1- Dec 31

Sampling requirements for the
group’s Medicare Part B patients

TABLE 1b: Summary of Quality Data Submission Criteria for the CY 2022 and 2023
MIPS Performance Periods for Individual Clinicians and Groups
Clinician Type
Individual
Clinicians

Submission Criteria

Measure Collection Types
(or Measure Sets) Available

Report at least six measures including
one outcome measure, or if an
outcome measure is not available
report another high priority measure;
if less than six measures apply then
report on each measure that is
applicable. Clinicians would need to
meet the applicable data
completeness standard for the
applicable performance period for
each collection type.

Individual MIPS eligible
clinicians select their measures
from the following collection
types: Medicare Part B claims
measures (individual clinicians
in small practices only), MIPS
CQMs, QCDR measures,
eCQMs, or reports on one of the
specialty measure sets if
applicable.

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Clinician Type

Submission Criteria

Measure Collection Types
(or Measure Sets) Available

Groups (non-CMS
Web Interface for
CY 2022 MIPS
performance
period; all groups
for the CY 2023
MIPS performance
period)

Report at least six measures including
one outcome measure, or if an
outcome measure is not available
report another high priority measure;
if less than six measures apply then
report on each measure that is
applicable. Clinicians would need to
meet the applicable data
completeness standard for the
applicable performance period for
each collection type.

Groups select their measures
from the following collection
types: Medicare Part B claims
measures (small practices only),
MIPS CQMs, QCDR measures,
eCQMs, or the CAHPS for
MIPS survey - or reports on one
of the specialty measure sets if
applicable.

Groups (CMS
Web Interface for
group of at least
25 clinicians for
the CY 2022
MIPS performance
period)

Report on all measures includes in the
CMS Web Interface collection type
and optionally the CAHPS for MIPS
survey.

Groups report on all measures
included in the CMS Web
Interface measures collection
type and optionally the CAHPS
for MIPS survey.

MVP Participant
(CY 2023 MIPS
performance
period)

An MVP Participant must select and
report 4 quality measures, including 1
outcome measure (or, if an outcome
measure is not available, 1 high
priority measure, included in the
MVP.

Groups of 16 or more clinicians
who meet the case minimum of
200 will also be automatically
scored on the administrative
claims based all-cause hospital
readmission measure.

Clinicians would need to meet the
applicable data completeness standard Groups of 16 or more clinicians
for the applicable performance period who meet the case minimum of
for each collection type.
200 will also be automatically
scored on the administrative
claims based all-cause hospital
readmission measure.
MVP Participants (individual
MIPS eligible clinician, single
specialty group, subgroup, or
APM Entity that is assessed on
an MVP) report on the
applicable measures and
activities in MVPs included in
the MVP Inventory.

As discussed in Supporting Statement A, we are proposing in the CY 2022 PFS proposed
rule to extend the CMS Web Interface measures as a collection type/submission type for groups
of 25 or more clinicians for the CY 2022 MIPS performance period/2024 MIPS payment year.
We are also proposing to sunset the CMS Web Interface as a collection type for groups of 25 or
more clinicians beginning with the CY 2023 MIPS performance period/2025 MIPS payment
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year. Beginning with the CY 2023 MIPS performance period/2025 MIPS payment year, these
groups will be required to use an alternate collection type which will have to be either the MIPS
CQM and QCDR measures or eCQM collection type.
For the CMS Web Interface, organizations (groups, Shared Savings Program ACOs) will
submit data on samples of the organization’s fee-for-service (FFS) Medicare beneficiaries that
will be selected by CMS. CMS plans to use a Medicare beneficiary sampling method similar to
that employed in the CY 2021 MIPS performance period/2023 MIPS payment year. The sample
will be drawn in the fourth quarter of the performance period (e.g., in October of 2022 for the
CY 2022 MIPS performance period/2024 MIPS payment year).
The first step in the CMS Web Interface quality measure sampling methodology is to
identify the beneficiaries eligible for quality measurement. The assigned patient population is
the foundation from which to measure quality performance. CMS will assign a Medicare
beneficiary to an ACO or group based on current program rules. For ACOs, CMS will use
beneficiaries assigned using the ACO assignment/alignment methodology. 2 For groups and
virtual groups, CMS will use beneficiaries assigned using the MIPS assignment methodology. 3
Using Medicare administrative data from January 1, 2022, through October 31, 2022, CMS will
exclude the following beneficiaries from quality measurement eligibility:
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Beneficiaries with fewer than two primary care services 4 within the organization, during
the performance year.
Beneficiaries with part-year eligibility in Medicare FFS Part A and Part B
Beneficiaries in hospice.
Beneficiaries who died.
Beneficiaries who did not reside in the United States.

The remaining beneficiaries will be considered eligible for quality measurement.
The second step in the CMS Web Interface quality measure sampling methodology is to
identify beneficiaries eligible for sampling into each measure. For beneficiaries identified as
eligible for quality measurement, we determine if they are eligible for any of the specific quality
measures based on the denominator criteria as outlined in the 2021CMS Web Interface Measure
Specifications and Supporting Documents. Due to limitations in the Medicare claims data, some
denominator exclusion and exception criteria must be applied by organizations using medical
record data. Diagnostic data from all claims for each assigned beneficiary are used to determine
whether that beneficiary has a particular condition such as diabetes, congestive heart failure,
2

The Shared Savings Program uses beneficiaries assigned in the third quarter of 2021. The Shared Savings Program
beneficiary assignment methodology can be found here: https://www.cms.gov/Medicare/Medicare-Fee-forService-Payment/sharedsavingsprogram/Financial-and-AssignmentSpecifications.html
3

The MIPS assignment methodology for the CMS Web Interface and CAHPS for MIPS Survey document can be
found on the CMS website at: https://www.cms.gov/Medicare/Quality-Payment-Program/ResourceLibrary/Resource-library.html.
4

As defined by the Healthcare Common Procedure Coding System (HCPCS) codes.

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coronary artery disease, or a range of other chronic conditions. A beneficiary may be counted in
one or more of each of those categories based on the number of conditions s/he has. The clinical
measure denominator criteria, such as age, gender, hospitalization, etc. are further applied to
each diagnostic sub-group of beneficiaries to determine which patients are eligible for data
submission on the measure.
CMS will select an initial random sample of 900 beneficiaries eligible for quality
measurement and populate them into the measures for which they are eligible until a sample size
of 616 is reached for each measure. If, after this step, a measure has fewer than 616
beneficiaries, CMS will select additional eligible beneficiaries until the measure has the required
616 or until there are no additional eligible beneficiaries available. When the beneficiary is
eligible for multiple measures, they will be included in multiple measures. Although this
sampling methodology does not guarantee that beneficiaries will have the same numeric rank
across measures, it does increase the likelihood that a beneficiary will have a similar rank across
measures. Therefore, a beneficiary with a low rank in one measure will likely have a low rank in
other measures that he or she is eligible. The intent of this approach is to reduce reporting burden
for the ACOs, groups, and virtual groups. For all measures, beneficiaries will be assigned a rank
between 1 and 616 based on the order in which they are populated into each measure sample.
For some measures and for some exclusions, CMS has applied exclusion criteria during the
sampling process. However, exclusions are not always applied during sampling, because
sometimes, it is not possible to do with claims data. If an organization is unable to report data on
a beneficiary at the time of abstraction, the organization must indicate a reason the data cannot be
reported. The organization must not skip a beneficiary without providing a valid reason, which is
defined as an exclusion in the CMS Web Interface measure specifications. The acceptable reasons
will be available for selection within the CMS Web Interface as well.
Data Submission for Promoting Interoperability and Improvement Activities Performance
Categories
During the CY 2022 and 2023 MIPS performance periods, eligible clinicians and groups
can submit Promoting Interoperability and improvement activities data through direct, log in and
upload, or log in and attest submission types.
Based on data from the CY 2019 MIPS performance period/2021 MIPS payment year
and CY 2020 MIPS performance period/2022 MIPS payment year eligibility data, we estimate
that 40,172 individual MIPS eligible clinicians and 11,475 groups will submit Promoting
Interoperability data for the CY 2022 MIPS performance period/2024 MIPS payment year. We
estimate that 40,172 individual MIPS eligible clinicians, 11,475 groups, and 20 subgroups will
submit Promoting Interoperability data for the CY 2023 MIPS performance period/2025 MIPS
payment year. These estimates reflect that under the policies finalized in CY 2017 and CY 2018
Quality Payment Program final rules and the CY 2019, CY 2020, and CY 2021 PFS final rules,
certain MIPS eligible clinicians will be eligible for automatic reweighting of the Promoting
Interoperability performance category to zero percent, including MIPS eligible clinicians that are
hospital-based, ambulatory surgical center-based, non-patient facing clinicians, physician
assistants, nurse practitioners, clinician nurse specialists, certified registered nurse anesthetists,
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physical therapists, occupational therapists, qualified speech-language pathologists or qualified
audiologist, clinical psychologists, and registered dieticians or nutrition professionals (81 FR
77238 through 77245, 82 FR 53680 through 53687, 83 FR 59819 through 59820, 84 FR 63003
through 63006, and section IV.A.3.c.(4)(e) of the CY 2021 PFS final rule, respectively). In
section IV.A.3.d.(4)(h)(iv) of the CY 2022 PFS proposed rule, we propose to apply the automatic
reweighting of the Promoting Interoperability performance category to clinical social workers.
These estimates also account for the automatic reweighting policies for clinicians who are in
small practices, as proposed in section IV.A.3.d.(4)(h)(i) of the CY 2022 PFS proposed rule. In
the CY 2020 PFS final rule, we revised the definition of a hospital-based MIPS eligible clinician
under § 414.1305 to include groups and virtual groups. We finalized that, beginning with the
2022 MIPS payment year, a hospital-based MIPS eligible clinician under § 414.1305 means an
individual MIPS eligible clinician who furnishes 75 percent or more of his or her covered
professional services in an inpatient hospital, on-campus outpatient hospital, off campus
outpatient hospital, or emergency room setting based on claims for the MIPS determination
period, and a group or virtual group provided that more than 75 percent of the NPIs billing under
the group’s TIN or virtual group’s TINs, as applicable, meet the definition of a hospital-based
individual MIPS eligible clinician during the MIPS determination period. We also specified that
for the Promoting Interoperability performance category to be reweighted for a MIPS eligible
clinician who elects to participate in MIPS as part of a group or virtual group, all of the MIPS
eligible clinicians in the group or virtual group must qualify for reweighting, or the group or
virtual group must meet the finalized revised definition of a hospital-based MIPS eligible
clinician or the definition of a non-patient facing MIPS eligible clinician as defined in
§ 414.1305.
As discussed in Supporting Statement A, a variety of organizations will submit
Promoting Interoperability data on behalf of clinicians. Clinicians not participating in a MIPS
APM may submit data as individuals or as part of a group. In the CY 2017 Quality Payment
Program final rule (81 FR 77258 through 77260, 77262 through 77264) and CY 2019 PFS final
rule (83 FR 59822-59823), we established that eligible clinicians in MIPS APMs (including the
Shared Savings Program) may report for the Promoting Interoperability performance category as
an APM Entity group, individuals, or a group.
As discussed in Supporting Statement A, we estimate 63,845 clinicians will submit
improvement activities as individuals, and an estimated 17,717 groups and virtual groups will
submit improvement activities on behalf of clinicians during the CY 2022 MIPS performance
period/2024 MIPS payment year. For the CY 2023 MIPS performance period/2025 MIPS
payment year, we estimate 63,845 individual clinicians, 17,717 groups and virtual groups, and 20
subgroups will submit improvement activities on behalf of clinicians.

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2. Describe the procedures for the collection of information including:
a.
b.
c.
d.
e.

Statistical methodology for stratification and sample selection,
Estimation procedure,
Degree of accuracy needed for the purpose described in the justification,
Unusual problems requiring specialized sampling procedures, and
Any use of periodic (less frequent than annual) data collection cycles to reduce
burden.

There are 26 information collections in the 2022 PRA package. Only 1 of the 26 information
collections in this information collection request involves sampling conducted by CMS. This
information collection is for the quality data submission using the CMS Web Interface and is
described below. As a result of the proposed policy in the CY 2022 PFS proposed rule to sunset
the CMS Web Interface measures as a quality performance category collection type/submission
type beginning with the CY 2023 MIPS performance period, we will no longer perform sampling
for any information collections included in this PRA package at that time. Table 1 (above)
provides information regarding the performance period, sampling, and completeness criteria for
all but one of the data submission mechanisms for MIPS eligible clinicians and groups to submit
quality measures data for the CY 2022 and 2023 MIPS performance periods/2024 and 2025
MIPS payment years. The requirements for the other quality data submission mechanism,
CAHPS for MIPS survey, are discussed in a separate information collection request submitted
under OMB control number 0938-1222. We do not anticipate using sampling or statistical
estimation in the remaining information collections.
3. Describe methods to maximize response rates and to deal with issues of non-response.
The accuracy and reliability of information collected must be shown to be adequate for
intended uses. For collections based on sampling, a special justification must be
provided for any collection that will not yield 'reliable' data that can be generalized to
the universe studied.
Quality Performance Category Data Submission
We expect additional experience with submissions under MIPS to clarify optimal data
completeness thresholds and submission criteria for use in future performance periods. We will
continually evaluate our policies and notify the public through future notice and comment
rulemaking if we make substantive changes. As we evaluate our policies, we plan to continue a
dialogue with stakeholders to discuss opportunities for program efficiency and flexibility.
We propose to sunset the CMS Web Interface measures as a quality performance
category collection type/submission type beginning with the CY 2023 MIPS performance
period/2025 MIPS payment year. Groups and virtual groups would have the option to adopt
similar eCQM or MIPS CQM measures in MIPS, select similar measures in an MVP, or be able
to select their own measures to report, would be reporting data on at least 6 measures, and data
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completeness threshold would be 80 percent for each measure. This would result in a reduction
in program requirements compared to the previously required reporting for all 10 CMS Web
Interface measures. In addition, the 10 CMS Web Interface measures that are required for
reporting under the CY 2021 performance period/2023 MIPS payment year have an eCQM and
MIPS CQM equivalent measure and for the CY 2022 performance period/2024 MIPS payment
year, there are 10 eCQMs and 9 CQMs that are equivalent to the 10 CMS Web Interface
measures. We believe that groups and virtual groups would be able to identify at least 6
equivalent eCQMs or MIPS CQMs (or a combination), or groups would also be able to identify 4
equivalent measures in an MVP that capture the same type of data collected for the measures
used in the CMS Web Interface.
We believe that by continuing to provide virtual group participation as an option we will
experience continued improvement in response rates due to the ability to better pool resources
from participating as part of a virtual group, allowing for reporting on 6 quality measures.
Promoting Interoperability Performance Category Data Submission
The revised scoring methodology finalized in the CY 2019 PFS final rule (83 FR 59791)
has provided a simpler, more flexible, less burdensome structure, allowing MIPS eligible
clinicians to put their focus back on patients. This scoring methodology encourages MIPS
eligible clinicians to push themselves on measures that are most applicable to how they deliver
care to patients, instead of focusing on measures that may not be as applicable to them. We
believe the increased flexibility to MIPS eligible clinicians that enables them to focus more on
patient care and health data exchange through interoperability will continue to help to maximize
response rates for the Promoting Interoperability performance category.
In the CY 2022 PFS proposed rule, we propose the additional requirement that eligible
clinicians must attest to conducting an annual assessment of the High Priority Guides of the
SAFER Guides beginning January 1, 2022. Clinicians will complete this attestation by checking
a box when they submit their Promoting Interoperability performance category data.
In the CY 2020 PFS final rule, we required QCDRs and qualified registries to be able to
submit data for each of the quality, improvement activities, and Promoting Interoperability
performance categories with the stipulation that based on the amendment to § 414.1400(a)(2)(iii)
a third party could be excepted from this requirement if its MIPS eligible clinicians, groups or
virtual groups fall under the reweighting policies at § 414.1380(c)(2)(i)(A)(4) or (5) or §
414.1380(c)(2)(i)(C)(1) through (7) or § 414.1380(c)(2)(i)(C)(9)). As a result, MIPS reporting
for clinicians who utilized qualified registries or QCDR that have not previously offered the
ability to report performance categories other than quality will be able to report MIPS data in a
more streamlined and less burdensome manner.
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Improvement Activities Performance Category Data Submission
User experiences from the 2019 MIPS performance period reflect that the majority of
users submit improvement activities data as part of the login and upload or direct submission
types which allow multiple performance categories (i.e., quality and promoting interoperability)
worth of data to be submitted at once. This results in less additional required time to submit
improvement activities data which consists of manually attesting that certain activities were
performed. In addition, the same improvement activity may be reported across multiple
performance periods so many MIPS eligible clinicians may submit the same information for the
CY 2022 and 2023 MIPS performance periods/2024 and 2025 MIPS payment years as they did
for previous MIPS performance periods/MIPS payment years. There is also financial incentive
to submit improvement activities data, as clinicians would not receive credit in their MIPS final
score otherwise. We believe a less burdensome user experience combined with the financial
incentives for submitting improvement activities data will continue to improve response rates in
the CY 2022 and CY 2023 MIPS performance periods/2024 and 2025 MIPS payment years.
4. Describe any tests of procedures or methods to be undertaken. Testing is encouraged
as an effective means of refining collections of information to minimize burden and
improve utility. Tests must be approved if they call for answers to identical questions
from 10 or more respondents. A proposed test or set of tests may be submitted for
approval separately or in combination with the main collection of information.
We are refining our procedures, methods and testing over time to be more efficient. We
do not have any additional testing to describe in this section, including no additional tests that
call for answers to identical questions from 10 or more respondents.
As stated above, we expect that additional experience with MIPS will clarify optimal
reporting thresholds and submission criteria for use in future performance periods across the
quality, Promoting Interoperability, and improvement activities performance categories. We will
continually evaluate our policies based on our analysis of MIPS and other data. For group
submission through the CMS Web Interface, we note that the methodology was derived from
commercially available methods used to compute quality measures in the commercial and
Medicare managed care environments and was previously used under the PQRS GPRO Web
Interface.
5. Provide the name and telephone number of individuals consulted on statistical aspects
of the design and the name of the agency unit, contractor(s), grantee(s), or other
person(s) who will actually collect and/or analyze the information for the agency.
We do not anticipate any additional statistical reporting on data other than that presented
here for the quality or Promoting Interoperability and improvement activities performance
categories.
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Quality, Promoting Interoperability, and Improvement Activities Performance Category Data
We anticipate that a contractor will analyze information collected from individual MIPS
eligible clinicians and groups submitting data to the quality, Promoting Interoperability and
improvement activities performance categories.
CMS Web Interface Quality Performance Category Submission
As noted above, we expect that the statistical methods for the CMS Web Interface data
submission option will be very similar to those developed for the GPRO Web Interface data
submission option. The methods were adopted from the PGP demonstration; the National
Committee for Quality Assurance (NCQA) and RTI International were consulted on the
development of the sampling methodology. A contractor will administer the sampling
methodology for the CMS Web Interface.

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