MIPS Data Completeness Requirement

The Medicare guidelines require a Patient Reported Outcome (PRO) measure be provisioned on a defined percentage of all patients eligible for the corresponding PRO measure(s) and who do not have any exclusions. To establish a patient's eligibility, you will need to mark the patient MIPS Qualified on the Episode of Care. The patient must be Qualified for every initial evaluation a patient attends.  

Quality Scoring: Data Completeness Requirement by Year 

2021: A minimum of 70%  data completeness is required to achieve the maximum points for each measure.
For Keet clients, their current data completeness is reflected as the compliance score in the Performance Reports.

When is a patient excluded from completing a MIPS PRO?

If a patient has an exclusion they will NOT count towards the minimum reporting requirements. Possible exclusions include:

    1. Patients will be automatically excluded from MIPS submission if they:

      • Are under the age of 18 years old

      • Are not under treatment related to one of the 5 CMS-approved measures (LEFS, MDQ, NDI, KOS, QDASH)

      • Do not complete 2 or more forms for an assigned measure

    2. Additionally, patients can manually be excluded (disqualified) from MIPS if they*:

      1. Are non-English speaking

      2. Are unable to read

      3. Have a mental impairment that compromises their understanding

      4. Are determined to be extremely medical complex and likely to make poor clinical progress based on the experience and clinical judgment of the treating clinician. 

        *In the event of a CMS audit, all manual patient disqualifications should be notated within the patient’s EMR visit note