MIPS Data Completeness Requirements

With the 2022 MIPS reporting year approaching, a question frequently asked is “what exactly does CMS mean when they say data completeness, especially with regard to the quality category?” To understand data completeness we first need to understand MIPS reporting requirements. MIPS reporting requires data on 6 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.

As you may be aware,  a denominator and numerator in MIPS 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 MIPS:

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. CMS requires 100% of the denominator data (denominator eligible instances)!

When reporting denominator eligible instances, make sure you are providing a numerator response (performance met, not met, or exception) for at least 70% of those instances. In fact, CMS prefers that providers report 100% of all numerator responses.  So, if you have 100 patients that are 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 groups, virtual groups, and 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:

  •  You should have started data collection on January 1, 2021, to meet data completeness requirements for the 2021 Performance Year, and you should report data all the way through to December 31st, 2021. If you fail to meet data completeness requirements, you’ll receive 0 points for the measure, unless you’re a small practice, in which case you’ll receive 3 points.
  •   The data completeness requirement is 70%, which means that 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.

So what does data completeness mean if we are reporting MIPS data at the group level? Do we have to report on data for all providers in the group, even if they are not eligible at the individual level?

Yes, if you choose to participate in MIPS as a group, you’ll need to collect and submit the available data from all of the clinicians within your group as appropriate to the quality measures you select. This includes data for clinicians that aren’t eligible for MIPS or a MIPS payment adjustment. For improvement activities, each improvement activity for which groups attest must be performed by at least 50% of the clinicians billing under the group’s TIN, and the clinicians must perform the same activity during any continuous 90-day period within the same performance year. When participating as a group, it is the group and not each individual MIPS eligible clinician, that must exceed the low-volume threshold at the group level. For the quality, cost, and improvement activities performance categories, performance is measured across all clinicians in the group, including those that aren’t MIPS eligible clinicians. For the Promoting Interoperability performance category, groups are required to submit the data collected in certified Electronic Health Record Technology (CEHRT) on behalf of their MIPS eligible clinicians.

**For more information reference the following