With the 2024 deadline for the retirement of Web Interface (aka GPRO) approaching, one of the most frequently asked questions is “what exactly does CMS mean when they say ‘data completeness’, especially with regard to the quality category under the new APP program?” To understand the term “data completeness”, we first need to understand APP reporting requirements for ACOs. APP reporting is the new program replacing Web Interface (GPRO) reporting, and requires data on 3 quality measures for the full performance year. This includes a minimum of 20 patients for each measure — and 100% of the denominator eligible instances for all payers, for each measure. This means there will probably be thousands of encounters for each of the 3 required measures.  

As you may be aware,  a denominator and numerator in APP reporting means the following, according to CMS:

“Quality measures consist of a numerator and denominator that are used to calculate data completeness and performance for a defined patient population as an indication of achievement for a particular process of care being provided or clinical outcome being attained. The denominator is the lower part of a fraction used to calculate a rate, proportion, or ratio. The numerator is the upper portion of a fraction used to calculate a rate, proportion, or ratio. The numerator focuses on the target quality actions defined within the measure. It may be a process, condition, event, or outcome. Numerator criteria are the measure defined quality actions expected for each patient, procedure, or other units of measurement defined in the denominator.”

According to the Quality Measure Requirements for APP:

You’ll need to report performance data (i.e. numerator responses) for at least 70% of all the patients (i.e. denominator eligible instances) who qualify for each measure. This is the 70% data completeness requirement.

What may not be immediately obvious is that the 70% data completeness requirement only refers to the numerator. It’s important to note that CMS requires 100% of the denominator data (denominator eligible instances).

When reporting denominator eligible instances, make sure you’re providing a numerator response (performance met, not met, or exception) for at least 70% of those instances. In fact, CMS prefers that ACOs report 100% of all numerator responses.  So, if you have 100 patients eligible for the measure, you’d need a numerator response on at least 70 of them. The other 30 could be left blank/not reported for the numerator according to statute, although it’s preferred to just answer for all of them when possible to avoid cherry-picking. 

What instances or circumstances are considered “acceptable” for potentially not reporting some numerator responses?

If a numerator cannot be reported on a small number of responses (30% or less), this would usually be for burden reduction, and/or technical/operational issues.  From statute:

“A data completeness criteria threshold of less than 100 percent reduces the burden and accommodates operational issues that may arise during data collection within the initial years of the program. We have previously provided notice to MIPS eligible clinicians in order for them to take the necessary steps to prepare for higher data completeness criteria thresholds in future years (82 FR 53632, 83 FR 59758, and 84 FR 62951). We want to ensure that an appropriate, yet achievable, data completeness criteria threshold is applied to all eligible clinicians participating in MIPS.

We recognize that there are technical and operational dynamics that APM Entities such ACOs must address, particularly the transition of multiple EHR systems to code and capture all-payer data that meets the data completeness criteria for eCQMs and/or MIPS CQMs. To ease the burden of transitioning to using an alternative collection type and/or submission type, we are extending the 70 percent data completeness criteria threshold, as described above.”

Some other important information concerning Data Completeness:

  • Data completeness of 70% only applies to CQMs. eCQMs require 100%. 
  • You should have started data collection on January 1, 2023, to meet data completeness requirements for the 2023 Performance Year, and you should report data all the way through to December 31st, 2023. If you fail to meet data completeness requirements, you’ll receive 0 points for the measure.
  • The data completeness requirement is 70%, which means you need to report numerator (performance met, not met, or exclusion/exception data) for at least 70% of patients or encounters that are eligible for the measure’s denominator.
  • Selectively reporting data that misrepresents your actual performance in a disingenuous manner, commonly referred to as “cherry-picking,” results in data that isn’t true, accurate, or complete and may subject you to audit.
  • If you’re working with a vendor or third-party intermediary to collect and submit data, make sure you work with them throughout the year on data collection.

As an ACO, can I use the 70% data completeness to “not report” on one or more of my participants?

Yes, you can “not report” on the numerators for one or more of your TIN participants as long as you are reporting on 70% of the total numerator responses for the ACO. Remember that this only applies to CQMs, so this means that if you have a mix of eCQM and CQMs for your participants, you will need to report to CMS using the CQM benchmarks. This is an effective strategy to deal with last mile integration where TIN participants are on paper or EHR technology that isn’t certified as it’s in line with the rationale that there are sometimes technical and operational issues precluding the ability to report all 100% of numerator responses. Keep in mind this still requires the reporting of 100% of the denominators, but this is typically easier to accomplish from TIN participants (given the denominator information can be derived from billing data). 

Still have questions? We’re here to help. Contact us here to learn more about ACO MSSP Data Completeness.