MACRA 2019 Part 3: Quality Measures

MACRA 2019 Part 3: Quality Measures

Now that you’ve determined eligibility, let’s work on understanding Quality Measures, which—as you’ll recall—make up 70% of your Composite Performance Score.


When reporting MACRA, two different types of measures can be tracked & submitted: MIPS Measures and Non-MIPS (QCDR) Measures.

MIPS Measures

MIPS Measures are published and controlled by CMS. They get approved in the fall of the year preceding the reporting year (2019’s MIPS measures were approved in Fall of 2018). Unfortunately, only 9 MIPS measures apply to the field of anesthesia, and of those 5, only a few apply to a majority of anesthesia cases. Because QPP participation was impossible for a specialty like anesthesia, CMS allowed for the creation of QCDRs (Qualified Clinical Data Registries), who are able to create their own measures that apply to a given specialty.

Non-MIPS Measures

Non-MIPS measures, also called “QCDR Measures,” are published and controlled by the QCDRs. These measures also have to be certified by CMS, a process that was completed in January of 2019.

A company like Graphium that specializes in MACRA reporting can select a combination of MIPS and Non-MIPS measures that will apply to the broadest section of anesthesia providers and set them up on the most probable pathway to positively adjusted reimbursements.


Understanding how scores are measured can be a challenge – especially when trying to navigate the MACRA waters on your own.

First of all, each measure is given a score of 0-10. How many points you get depends upon two factors: Performance Met and Benchmarking.

Performance Met is a percentage of qualified cases for which a MACRA measure’s criteria were met. CMS will compare an individual’s Performance Met percentage against the performance of all other QPP participants. They will then create deciles – each of which containing a range of Performance Met percentages – while will represent the score (1-10) that the individual receives for the measure in question.

See? Challenging.

Perhaps the chart below will help. Three MACRA measures are listed in the table under “Measure_Name.” For an example, we’ve highlighted the 2nd and 3rd MACRA Measures and assumed that an individual has achieved equal performance for both of them: a “Performance Met” score of 99.3%.

However, the Performance Met scores have been benchmarked and separated into deciles. After benchmarking, you can see that one measure with a 99.3% performance met score is in the 9th Decile and receives a score of 9. The provider received the same performance met score of 99.3% on another measure (“Measure Y”), but higher performance was more common program-wide, which changed the decile ranges. Unfortunately, even though the performance score is the same as the other measure, in this case it only qualifies for a score of 5 out of 10.

Regardless of decile ranges, though, a “Performance Met” score of 100% always receives 10 out of 10 possible points.


Over 200 MIPS measures were released by CMS, but only 9 of those measures actually applied to general anesthesia, and, as mentioned earlier, even fewer were helpful. More measures are available from QCDRs, though. 6 measures are available from the ABG (Anesthesia Business Group) QCDR, and 15 measures are available from the AQI (Anesthesia Quality Institute) QCDR.

In total, there are 30 “Anesthesia” specific quality measures. Like years past, all of these measures will require CPT Codes & CPT Reconciliations for reporting, regardless of whether they are MIPS or Non-MIPS measures or from which QCDR they came. Graphium Health has built a process for CPT Reconciliation, and we’re happy to answer any questions you have at any time.

With all of that in mind, the Graphium Health team got to work in February selecting measures for our customers to report. Clearly, we needed to focus on three criteria:

  • The Measure applies to >20 cases for each provider (to ensure that the measure qualifies for reporting)
  • The Measure has favorable benchmarking (to maximize your quality score potential)
  • The Measure requires minimal data capture burden from the providers (to minimize any additional work)

Foregone Measures

ABG 39 Preoperative Active Warming Percentage of patients, aged 18 years and older who present for colorectal surgery with regional or general anesthesia who have core temperatures checked preoperatively within one hour prior to induction of anesthesia and, when less than 36C, have acting warming measures applied
AQI 56 Use of Neuaxial Techniques and/or Peripheral Neve Blocks
Percentage of patients, regardless of age, that undergo primary total knee arthroplasty for whom neuraxial anesthesia and/or a peripheral nerve block is performed.
MIPS 76 Prevention of CVC – Related Bloodstream Infections Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation, and, if ultrasound is used, sterile ultrasound techniques followed.


This chart shows a few measures that Graphium Health decided against for our customers. These 3 measures were a little too specific. When you read the reporting criteria (right-hand column) closely, you’ll realize that, for many providers, the description is so finite that it will apply to too few cases to qualify for reporting. For instance, ABG 39 (Preoperative Active Warming) sounds promising. But upon close review of the description, you’ll see that the measure only applies to patients who are 18 years or older who present for colorectal surgery. So if you are an eye center, working in pediatrics, or a day surgery center, you may not see any cases to which this measure applies.

Too Complex

AQI 55 Team-Based Implementation of a Care-and- Communication Bundle for ICU Patients % of patients who are admitted to an ICU for 48 hrs & received crit. care services who have documentation by managing phys. of 1) attempted/actual identification of surrogate decision maker, 2) advance directive, & 3) patient’s preference for cardiopulmonary resuscitation, within 48 hours of ICU admission.
AQI 48 Patient- Reported Experience with Anesthesia % of patients, regardless of age, that undergo primary total knee arthroplasty for whom neuraxial anesthesia and/or a peripheral nerve block is performed.


These two measures have requirements that are too complex. An overly complex measure tends to require more detailed information about the case at hand, which translates to far more data entry on the part of the provider. To Graphium, this is a HUGE negative. Take a look at AQI 56 (Team-Based Implementation of a Care-and- Communication Bundle for ICU patients). This measure would require that providers track which patients are admitted to the ICU and then follow up with them 48 hours later, at which point more data entry would be required. As a result, Graphium opted to let this measure go in favor of measures that are simpler to capture.