To run the CMS WI Random Sample Performance Report, click on Quality from the menu bar and click on QM Performance Score under the QM Performance menu.
To Run for CMS WI Random Sample, choose CMS WI Random Sample from Report Type Drop down and choose current year
The next step is to choose patients to base report on:
a) Required sample (248+skips)
b) Consecutively answered patients
c) Optimal sample
d) Full Population
Next choose to view score for:
a) Completed Measures Only
b) All Measures
The next set of filters are optional and used to narrow down your population to a specific, Division, TIN, SubGroup and NPI. Choose the options you prefer from the drop downs. If you leave filters open you will see for the full population you have access to.
Once you have selected all the necessary filters, click to run the report.
Your report will show below the filters. You will have three views available: Clicking on each view will change what you see on the screen.
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You will also have the option to Export your report to excel. You have a choice of:
The far left of the report shows practice specific information, including Practice Name, NPI, Total # of Attributed Patients and Total # of Completed / Not Qualified Patients. This information is useful for knowing the breakdown of patients based on practice, and relates to the overall total score farther to the right of the report. You may click a practice name to expand rows and show individual NPIs within the practice or you may click Expand All at the top of your report to show NPIs for each practice.
The middle of the report shows each quality measure to be reported on with the CMS Benchmark in the header if available. Below the header you will see a row for each practice in your ACO or if a practice level user you will only see information available for your practice. The report will reflect either Percentages, Points/Score or Numerator/Denominator depending upon which Default option you have chosen above. You also have the ability to switch between views in each box on the report individually by just clicking in the report.
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The total score to the right of your report will also change depending on the default view selected. Your total score will be broken down into the following views.
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Points % - This will be calculated by dividing earned points by possible points.
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Points - This will show how many points you have earned for each measure.
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Average Score - This is calculated by totaling the percentage score in each of the 10 scored measures, then dividing by the total number of scored measure to find the average based on all scores.
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At the bottom of the report you will see the following information totals across all listed practices:
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Total Score - This percentage is calculated by dividing each measure's numerator by the denominator.
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Numerator / Denominator - This will indicate the total of performance responses versus total applicable patients in the measure. The closer the numerator is to the denominator the higher your score will be.
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Points Earned - Shows the number of points earned per module. Depending on the percentile score for the ACO or Facility, this will be up to a maximum of 10 if the 90th percentile benchmark has been reached for the module.
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As a result of the transition to the APM Performance Pathway (APP) there's not a pay-for-reporting option, consistent with MIPS. Measures within the APP measure set that do not have benchmarks (N/A measure) for the CMS Web Interface for the performance period are not scored and no points are granted for them; they are, however, required to be reported in order to complete the Web Interface dataset.
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10 Points are granted if no patients in the denominator
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The DM-2 measure is scored inversely (the lower score indicates better quality)
Measure Bonus Points
Beginning with the 2022 performance period, there are no bonus points available for CMS Web Interface reporting. Bonus points have been removed in the quality performance category for reporting additional outcome and high priority measures (beyond the required) or for measures that meet end-to-end electronic reporting criteria.
How Performance Points are Calculated