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How To Calculate Data Completeness


MIPS reporting Quality 2022 Ophthalmology

Calculating data completeness is a necessary, but confusing step in MIPS Quality reporting. Skipping this step could not only lead to incorrect submissions, but also to a lower MIPS Quality score. That's why we created this handy data completeness calculation guide.

In this blog, we will cover what data completeness is and the potential impacts of ignoring it. 

What is Data Completeness?

Data completeness is the percent of total data that is reflected in reported data. MIPS data completeness is a criteria considered by the Centers for Medicaid and Medicare Services (CMS) to evaluate whether or not the data reported for each measure reflects performance comprehensively. For MIPS Quality measures, data completeness is the percentage of instances eligible for a specific measure that can be included in the measure's performance rate calculation.

For example, for Measure 117: Diabetes: Eye Exam, the eligible cases (also known as the denominator-eligible population) are all patients seen during the performance year who are ages 18-75 and who have diabetes. The data completeness reported for this measure would be the percentage of all of these denominator-eligible cases for which the quality action (whether or not an eye exam is performed) is reported on to CMS.

What is the Data Completeness Threshold?

For MIPS, CMS has established a minimum threshold of data completeness. CMS expects those reporting within MIPS to meet this threshold and, thus, to have enough performance data for each measure to be objectively and fairly scored. 

The current MIPS data completeness threshold is 70%. This means that you must report on at least 70% of your eligible instances for each quality measure during the performance year. You can learn how to evaluate your own records and how to troubleshoot if you appear to be under the data completeness threshold using our guide. Most practices that use an EHR assume that they will be at 100%, but, here at MarsdenAdvisors, we've seen a few exceptions that can impact any practice, including those using an EHR. 

What Happens if I Don't Meet the Data Completeness Threshold?

If you do not meet the data completeness threshold on a MIPS Quality measure, your score on that measure will be limited. The measure score you are able to receive if you do not meet data completeness depends on your practice's size:

  • Small practices (15 or fewer clinicians): 3 points on measures that do not meet data completeness.
  • Larger practices (16 or more clinicians): 0 points on measures that do not meet data completeness.

If you do not meet data completeness on each quality measure, you will end up with a lower MIPS score. 

Data completeness is one of the essential considerations for your Quality score, so it is worth learning how to verify that your data isn't lacking. 

Next Steps

  • Make sure you've downloaded our guide on data completeness
  • Share this information with your practice colleagues.
  • Contact your Client Success Manager if you have any questions. 
  • If you’re not a MarsdenAdvisors client and you want hands-on, personalized assistance, contact us and we will have your back.

If you have any questions on this, let us know!

 

Juliette Walle

Written by Juliette Walle

Juliette Walle is a Health Policy Analyst at the consulting firm MarsdenAdvisors.

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