QM Performance Report

To access the QM Performance Report, click on Quality from the menu bar and click on QM Performance Score under the QM Performance menu.

QM Scoring Report Filters

1) Choose QM from the drop down menu to run for QM (CMS Web Interface Measures)

2) Select Year from the drop down for the performance year you would like to review.

3) Full Population is the only option for Based On when selecting QM.

4) Choose Score Completed Measure Only or Score All Measures from the Completed/All drop down.

5) Select the Effective Period you would like to review data for from the drop down options.

By default this report will show all Divisions, TINs, SubGroups and NPIs. If you would like to filter to view specific Divisions, TINs, SubGroups and NPIs choose from the appropriate drop down options. Multi select is available for these drop downs.

Once you have completed your filter selections click the button to run the scoring 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.

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.

Clicking in one of the individual cells will drill to the CMS Web Interface grid for the performance year chosen. The drill down will show all patients with an incomplete or non-performance answer for the selected measure.

A White cell means met the 90%, Gray cell means NOT met 90%. N/As are defaulted to white as met the 90%.

The Total Score is on the right side of your report. Depending on the view selected you will see:

Points % - Calculated by dividing earned points by possible points.
Points - This will show total points earned. (Max Points 70)
Average % - Calculated by Total Numerator divided by total Denominator. (When calculating inverse measures (DM2) the numerator is subtracted from denominator and the result is used as actual numerator value) The average percentage is used for comparison purposes only.

At the bottom of the report you will see the following totals:

Total Score - This percentage is calculated by dividing each measure's numerator by the denominator.
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.
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 per measure or 80 points total. MH and Prev-13 are required for reporting, however no points are scored for these measures and a score of N/A will be shown.

(Points earned has been updated to two decimal places to better match what is showing in the QPP Portal)

Clicking in the total score boxes will drill to all patients with an incomplete or non-performance answer for selected population.

How Performance Points are Calculated

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.
10 Points are granted if no patients in the denominator
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 one required) or for measures that meet end-to-end electronic reporting criteria.