Track Change - Appendix F3: 2023 Peer Reviewed Journal Article Requirement Template

2023 MIPS Peer-Reviewed Journal Article Requirement Template

Section 101(c)(1) of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires submission of new measures for publication in applicable specialty-appropriate, peer-reviewed journals prior to implementing in the Merit-based Incentive Payment System (MIPS). These measures will be submitted by the Centers for Medicare & Medicaid Services (CMS), to a journal(s), before including any new measure in the MIPS Quality Measures List under MIPS. The measure submitter shall provide the required information for article submission under the MACRA per the CMS Call for MIPS Quality Measures submission process.

Stakeholders submitting measures to the MIPS Call for Quality Measures must complete the required information by the Annual Call for Measures deadline. Some of the information requested below may be listed in specific fields in the Measures Under Consideration (MUC) Entry/Review Information Tool (MERIT); however, to ensure that CMS has all of the necessary information and to avoid delays in the evaluation of your submission, please fully complete this form as an attached Word document. The information in MERIT must be consistent with the information below, which includes the following, but is not limited to:

• [Measure Title]

• [Meaningful Measures 2.0 Framework Domain]

Measure Steward: [Name]

Measure Developer: [Name]

Description: [Text]

1. Statement

• Background (Why is this measure important?).

• Environmental scan (Are there existing measures in this area?).

2. Gap Analysis

• Provide evidence for the measure (What are the gaps and opportunities to improve care?).

• Expected outcome (patient care/patient health improvements, cost savings).

• Recommendation for the measure (Is it based on a study, consensus opinion, USPSTF recommendation etc.?).

3. Reliability/Validity

• What testing has been performed at the level of implementation? (MIPS requires full measure testing at the individual clinician level (and may also need to be tested at the group level) for MIPS Clinical Quality Measures (CQMs) and Electronic Clinical Quality Measures (eCQMs) collection types. Administrative claims measures tested at the group level require a reliability threshold to be implemented at the group level.)

Please provide testing results including the N value, Bonnie test case results, correlation coefficient and any other pertinent information or values to be considered.

• Reliability Testing Results at the accountable entity level

• Face Validity Testing Results, Clinician Sites

• Empiric Validity Testing Results at the accountable entity level

• Data Element/Patient Encounter Level Testing

• Exclusion Frequency

• What were the minimum sample sizes used for reliability results?

• Other Information

• Is it risk adjusted? If so, how?

• What benchmarking information is available?

• Collection Type: Specify the data collection type.

• Specify measure stage of development.

• For Patient Reported Outcome Performance Measures:

• The survey or tool has been tested and does not require modifications based on results?

• Patient/encounter level testing for each critical data element does not require changes to the tool base on the results?

4. Endorsement

• Provide the Consensus-Based Entity (CBE) endorsement status (i.e., National Quality Forum (NQF)) (and CBE ID) and/or other endorsing body (If the measure is only endorsed for paper records, please note endorsement for only the data source being submitted.).

5. Summary

• Alignment with CMS Meaningful Measures Initiative or MACRA (if applicable).

• Relevance to MIPS or other CMS programs.

• Rationale: Use of measure for inclusion in program (specialty society, regional collaborative, other).

• Public reporting (if applicable).

• Preferable relevant peer-reviewed journal for publication.

• Rationale as to how the measure correlates to existing cost measures and improvement activities, as applicable and feasible.

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 0938-1314 (Expiration date: 01/31/2025). The time required to complete this information collection is estimated to average 2 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 QPP at [email protected].

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