Your final 2022 MIPS Group and Individual submission data have been compiled corresponding to your Organization's Tax Identification Number(s) (TIN) and for each provider’s individual National Provider Identifier (NPI) associated with the TIN. This data will be submitted to CMS pending certification of your reporting type. Please note, individual patient data is not submitted to CMS as part of this process. The final 2022 MIPS submission data should be reviewed carefully to confirm your reporting type and your intent for Keet Health to submit your MIPS data to CMS on your behalf for the 2022 MIPS performance year.
To finalize your 2022 MIPS submission, review the final 2022 Group and Individual MIPS submission data published within the Keet Submission Dashboard located within QuickSight. Once complete, submit the 2022 MIPS Submission Attestation Form to certify your reporting type and intent for Keet Health to submit your MIPS data to CMS.
Note
The information in the MIPS submission dashboard may vary from what is in the Keet Outcomes Dashboard v3.1. due to how exclusion populations are applied in the final submission. Additionally, EOCs without an assigned supervising provider will not be included in Individual submissions because an NPI must be associated to each EOC for this reporting type. Because Group or Group + Individual submissions include these EOCs there may be discrepancies in the dashboard submission totals relative to those EOCs that are being included with group versus individual.
Report Components & Definitions
Submission Summary Report
Use the Submission Summary report to assess performance for MIPS submission.
Please note: only the providers who have consented to individual submission will be included in the individual sections of this report.
Displays the number of MIPS measures where the TIN's/practictioner's Risk-Adjusted Average FTP rate was lower (positive performance) than the Keet Avg RA FTP rate. Additional columns indicate if the Keet Avg RA FTP rate was outperformed by 0-4.9%, 5-10%, or >10%.
Unlike the IROMS measures, the Dizziness Handicap Inventory (DHI) outcome measure is not an inverse measure, therefore the ‘Performance Met’ numerator option for this measure is the representation of better clinical quality or control. In other words, the DHI displays the percentage of patients who have progressed rather than those that have failed to progress. See the table below for how this translates to the Keet Outcomes Dashboard.
IROMS Quality Measures
| Submission Dashboard Name | KOD Name | Meaning |
| Performance_Met | FTP Population | Cases that did not meet or exceed the MCID. |
| Performance_Not_Met | Progressed Population | Cases that met or exceeded the MCID. |
DHI Quality Measure
| Submission Dashboard Name | KOD Name |
Meaning |
| Performance_Met | Progressed Population | Cases that did meet or exceed the MCID. |
| Performance_Not_Met | FTP Population | Cases that did NOT meet or exceed the MCID. |
Submission Summary All Strata Report
In the final submission, Keet Outcomes QCDR provides multiple groupings of your quality performance data to CMS. CMS uses the risk-adjusted overall strata for final scoring as surfaced in the submission summary tab. Additionally, Keet has provided you all submission strata for optional review. This is displayed under the submission summary, all strata report. Below are two similar tables that display the measure specification populations for each of the IROMS quality measures of the 6 CMS reported strata, and the DHI quality measure for the 4 CMS reported strata. A Strata is a grouping of patients according to particular CMS-defined criteria.
IROMS Quality Measures Strata
| Strata | Treatment | Definition |
| Observed | NonOp MCID | The proportion of [conservative] patients not achieving an MCID. |
| Observed | Operative MCID | The proportion of [surgical] patients not achieving an MCID. |
| Observed | Not Achieving | Overall proportion of patients not achieving an MCID. |
| Risk-Adjusted | NonOpRisk | A risk-adjusted MCID proportional difference will be reported where the difference between the risk model-predicted and observed MCID proportion will be reported. |
| Risk-Adjusted | OpRisk | A risk-adjusted MCID proportional difference will be reported where the difference between the risk model-predicted and observed MCID proportion will be reported. |
| Risk-Adjusted | Overall | A risk-adjusted MCID proportional difference will be reported where the difference between the risk model-predicted and observed MCID proportion will be reported. |
DHI Strata
| Strata: | Criteria: |
|
Submission Age Criteria 1 |
Patients aged 14-17 years of age |
| Submission Age Criteria 2 | Patients aged 18-64 years of age |
| Submission Age Criteria 3 | Patients aged 65 years and older |
| Submission Age Criteria 4 | Overall total rate of patients aged 14 years and older |
2022 Final MIPS Submission Data Review FAQs
How is scoring impacted if the 70% Compliance Rate or 20 Case Minimum requirement is not met?
Outlined below are the 3 scenarios used to calculate the scoring for each outcome measure. Note that for 2022, if you have not met the case minimum on 6 out of 10 measures, you may be at risk of a negative payment adjustment.
For additional information on scoring, refer to the QPP Traditional MIPS Scoring Guide.
| Scenario by Measure | Description | Scoring Rules Per Measure |
| 1 |
The measure can be scored based on performance. The measure meets all of the following criteria: |
Scenario 1 measures will be awarded 0 to 10 points based on performance compared with the benchmark. |
| 2 | The measure does not meet the 70% data completeness requirement. |
Scenario 2 measures will be awarded 0 points, except for small practices, which will receive 3 points.
|
| 3 | The measure meets the 70% data completeness requirement but does not have at least 20 cases. |
Scenario 3 measures will be awarded 3 points. |
Do these reports include the CMS benchmark I will be graded against?
No, Medicare will calculate the benchmark for 2022 after all data has been submitted.
Why are there only 6 PRO measures by TIN and Individual NPI
The IROMS PRO measure is actually listed twice: once for the PROM measure and again for the corresponding PRO numeric pain scale rating (NPRS). You may need to scroll within the Performance Report to view the pain measures.
- KOS - IROMS 11
- KOS NPRS - IROMS 12
- LEFS- IROMS 13
- LEFS NPRS- IROMS 14
- NDI- IROMS 15
- NDI NPRS- IROMS 16
- MDQ- IROMS 17
- MDQ NPRS- IROMS 18
- DASH- IROMS 19
- DASH NPRS- IROMS 20
- DHI/HM07
What Improvement Activities are reported?
Keet helps you achieve the maximum available points for the Improvement Activities category by satisfying and reporting on the following measures:
- IA_BE_6: Collection and follow-up on patient experience and satisfaction data on beneficiary engagement
- IA_BE_7: Participation in a QCDR, that promotes use of patient engagement tools
- IA_BE_8: Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive
- IA_BE_22: Improved Practices that Engage Patients Pre-Visit
- IA_AHE_3: Promote Use of Patient-Reported Outcome Tools
Can Keet review my data to tell me how to report or assess my performance?
No, we cannot advise on specific performance or decisions other than to offer the guidance and process requirements documented by CMS. For more information on how MIPS Quality Measures are scored, CMS has provided the 2022 MIPS Scoring Guide.
The dashboards display separate rows for IROMS measures related to the same region of injury, one for function and the other for pain. However, each row shows both the function and pain scores. Is this how it is supposed to display?
Yes, the IROMS functional and pain measures related to the same region of injury will display scores for both pain and function in each row. This relates to how the information is captured in our surveys and is presented this way for those who want to view the pain and function scores together.