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CMS Change to 2021 MIPS Performance Measures Calculation

On December 30, 2021, the Centers for Medicare & Medicaid Services (CMS) released changes which impacted the following MIPS Quality Measures (QM) for the 2021 Performance Period:

  • QM111 — Pneumococcal Vaccination Status for Older Adults.
  • QM128 — Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan.

Measure Truncated
QM111 — Pneumococcal Vaccination Status for Older Adults: CMS has truncated this measure to only score the first 9 months of the 2021 performance period. We plan to make a change to the measure reporting timeframe calculation to reflect the new CMS rule and include patients only within the first 9 months of 2021.

  • If you were planning to submit QM111, you will need to wait until this change is released in gGastro® prior to your MIPS submission. We plan to make this change available in an upcoming release, anticipated to be ready in late January 2022.
  • If you have already submitted your 2021 Quality Measures to CMS and included QM111, you will need to resubmit your Quality Reporting Document Architecture (QRDA) file after the data for QM111 is truncated in gGastro. This will require you to update to the gGastro version that contains this change.
  • Please note this does not impact QM111 for the 2022 Performance Period.

Measure Suppressed
QM128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan: CMS has determined that this measure has undergone a significant change that may result in misleading results, due to a misalignment between the measure narrative and logic of the measure. As a result, the measure will be suppressed for performance year 2021. This means that the measure will not be scored, and that if submitted, the total available measure achievement points will be reduced by 10 points.

You can read more about this announcement by accessing this document published in the Resource Library of the website.


The ModMed Gastroenterology Team



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