How to Use the Measure Calculation file
The Measure Calculation file was created to determine
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Performance based on the raw data from Quality Measure (QM) reports
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Performance on Promoting Interoperability (PI)
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Overall performance for QM, PI, and Improvement Activities
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Performance projection based on current performance and remaining time in the reporting period
This file is designed to be per provider using their top 6 performing QMs.
In order to create this file, you must first have the following:
- Numerator, Denominator and Performance Rate values from the Quality Measure and Promoting Interoperability reports in WRS.
- Decile score for each quality measure.
INSTRUCTIONS FOR MEASURES YTD TAB
1. Paste measure values into the Year To Date columns of the Measure Calculation file.
Quality Measures:
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Benchmark ID
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Measure Name
- Numerator and Denominator from WRS Report to auto-populate the % column
- Exclude - denominator exclusion value from WRS Report
- Decile # to auto-populate the Total Points column. Decile # is unique for each measure.
- To get the decile score for each performance rate, go to the 2023 MIPS Historical Quality Benchmarks file and look up the corresponding performance rate of the measure CMS ID.
Promoting Interoperability
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Numerator, Denominator, and Performance Rate values from WRS Report to auto-populate the % and Total Points columns.
2. Complete data in Projection Columns to to get the max projection score estimate for each measure. The projection is based on the following:
- How many patients were seen for each measure up to the last day of the report date range
- How many patients will be seen for each measure by the end of the performance period.
Quality Measures
- Weeks Past - # of weeks that have passed (last week of current YTD range).
- Weeks Remaining - # of weeks remaining in the current year
- Decile - decile based on Proj Year % and benchmark file
Promoting Interoperability
- Weeks Past - # of weeks that have passed (last week of current YTD range).
- Weeks Remaining - # of weeks remaining in the current year
Projection also helps to determine which measures have the best opportunity for growth. Difference = Projected points - Total Points.
If a measure has a lower number in Difference, it will be less beneficial to push on that measure, whereas time would be better spent improving the performance of a measure with a larger
Difference.
OVERALL CALCULATION TAB
The Overall Calculation tab calculates the overall total performance for Quality Measures, Promoting Interoperability and Improvement Activities.
- QM & PI content is pulled from the previous tab, so make sure the data entry is correct in the first tab.
- All grey fields have calculations built in, DO NOT CHANGE THE CALCULATIONS without consulting your manager.
REWEIGHT FACTORS
There are exclusions and exceptions that permit re-weighting of certain measures into another, or entire categories into another. These reweights have a direct impact on the total performance as categories and individual measures carry different weight.
Each column has a comment on how the possible reweights can be used.
This is very important because utilizing these exclusions and exceptions can mean the difference between passing and failing.
INSTRUCTIONS FOR OVERALL CALCULATION TAB
1. Copy the decile points in Column B and Paste as Values to Column C. DO NOT COPY AND PASTE NORMALLY.
2. Copy the decile points in Column M and Paste as Values to Column N. DO NOT COPY AND PASTE NORMALLY.
3. In the Improvement Activities line, enter 40 in Columns B and M.