(a) ASM performance year for quality measures. Beginning with 2029 ASM payment year, the ASM performance year for quality measures is the full calendar year from January 1 to December 31 that occurred 2 years prior to the applicable ASM payment year, except as otherwise specified for administrative claims-based measures.

(b) Quality measures for ASM heart failure cohort. CMS uses the following quality measures, as specified by CMS for the MIPS quality performance category unless otherwise stated, to assess performance for ASM heart failure participants in the quality ASM performance category:

(1) Risk-Standardized Acute Unplanned Cardiovascular-Related Admission Rates for Patients with Heart Failure for the Merit-based Incentive Payment System (MIPS Q492).

(2) Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) (MIPS Q008).

(3) Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD) (MIPS Q005).

(4) Controlling High Blood Pressure (MIPS Q236).

(5) Functional Status Assessments for Heart Failure (MIPS Q377).

(c) Quality measures for ASM low back pain cohort. CMS uses the following quality measures, as specified by CMS for the MIPS quality performance category unless otherwise stated, to assess performance for ASM low back pain participants in the quality ASM performance category:

(1) Use of High-Risk Medications in Older Adults (MIPS Q238).

(2) Preventive Care and Screening: Screening for Depression and Follow-Up Plan (MIPS Q134).

(3) Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan (MIPS Q128).

(4) Functional Status Change for Patients with Low Back Impairments (MIPS Q220).

(d) Removal, addition, and maintenance of technical specifications of quality measures. CMS uses notice-and-comment rulemaking to communicate any updates or changes to the quality measure sets described in paragraphs (b) and (c) of this section.

(e) Data submission criteria for the quality ASM performance category. (1) CMS uses quality measures as described in paragraphs (b) and (c) of this section with the following data collection types:

(i) MIPS CQMs.

(ii) eCQMs.

(iii) Administrative claims-based.

(2) Data submission requirements. (i) An ASM heart failure participant must submit data on all quality measures specified in paragraph (b) of this section using MIPS CQMs or eCQMs.

(ii) An ASM low back pain participant must submit data on all quality measures specified in paragraph (c) of this section using MIPS CQMs or eCQMs, unless otherwise stated.

(iii) For eCQMs, the submission of data requires the utilization of CEHRT, as defined at § 414.1305.

(3) An ASM participant is not required to submit data for the calculation of administrative claims-based measures so long as data submission requirements as specified at § 512.720(a)(1)(i) are met.

(f) Data completeness requirement for the quality ASM performance category. (1) Except as specified at paragraph (e)(3) of this section and for each required measure specified in paragraphs (b) or (c) of this section, ASM participants must submit data on at least 75 percent of the ASM participant's patients that meet the measure's denominator criteria, regardless of payer.

(2) ASM participants receive zero measure achievement points for each measure required in paragraphs (b) or (c) of this section that does not meet the data completeness requirement, as specified at paragraph (f)(1) of this section.

(3) CMS excludes from an ASM's participant total measure achievement points and total available measure achievement points any measures required under paragraphs (b) or (c) of this section that meet the respective measure's data completeness requirement, but do not have a benchmark.

(g) Minimum case requirements. (1) Unless otherwise specified by CMS, the minimum case requirement for each quality measure required in paragraphs (b) or (c) of this section is 20 cases.

(2) CMS excludes from an ASM's participant total measure achievement points and total available measure achievement points any measures required under paragraphs (b) or (c) of this section that meet the respective measure's data completeness requirement as specified at paragraph (f)(1) of this section but do not meet the measure's case minimum requirement as specified at paragraph (g)(1) of this section.

(h) Quality measure achievement points and quality ASM performance category scoring. Unless a different scoring weight is assigned by CMS, performance in the quality ASM performance category comprises of 50 percent of a ASM participant's final score for each ASM payment year.

(1) Measure achievement points. (i) For each ASM performance year, ASM participants receive between 1 and 10 measure achievement points (including partial points) for each required measure as specified in paragraphs (b) or (c) of this section on which data is submitted in accordance with paragraph (e) of this section that does all of the following:

(A) Has a benchmark specified in paragraph (h)(2) of this section.

(B) Meets the case minimum requirements specified in paragraph (g) of this section.

(C) Meets the data completeness criteria specified in paragraph (f) of this section.

(D) For each administrative claims-based measure with a benchmark as described at paragraph (h)(2)(iii) of this section and meets the case minimum requirement at paragraph (g) of this section.

(ii) The number of ASM measure achievement points received for each measure is determined based on the applicable benchmark decile category and the percentile distribution.

(iii) ASM participants receive zero ASM measure achievement points for each measure required in paragraphs (b) or (c) of this section on which no data is submitted in accordance with § 512.720.

(iv) ASM participants who submit data in accordance with paragraphs (e) through (g) of this section on a single required measure via multiple applicable collection types are scored only on the data submission with the greatest number of measure achievement points.

(2)(i) Benchmarks. Except as provided in paragraph (h)(2)(iii) of this section, CMS bases benchmarks on an ASM participant's performance by collection type, from one following data sources:

(A) Reported by ASM participants, to the extent feasible, during the ASM performance year.

(B) A previous ASM performance year, if available.

(C) Another period determined by CMS.

(ii) Each benchmark must have a minimum of 20 ASM participants who reported the measure having met the following criteria:

(A) The case minimum requirements in paragraph (g) of this section.

(B) The data completeness requirement as specified in paragraph (f) of this section.

(C) A performance rate that is greater than zero.

(iii) CMS calculates a benchmark for an administrative claims quality measure using the performance on the measure during the current ASM performance year.

(iv) CMS determines a benchmark using decile categories based on the applicable period of data used to determine the measure's benchmark.

(3) Topped out measures. CMS identifies topped out measures in the benchmarks for each ASM performance year based on within-model performance on each measure.

(4) Calculation of the quality ASM performance category score. (i) Unless otherwise specified by CMS, an ASM participant's quality ASM performance category score is the sum of all measure achievement points assigned for the applicable measures for the quality ASM performance category.

(A) The sum is divided by the total available measure achievement points.

(B) The quality ASM performance category score cannot exceed 100 percentage points.

(ii) For each measure that is submitted, if applicable, and impacted by significant changes or errors prior to the applicable data submission deadline at § 512.720(d), performance is based on data for 9 consecutive months of the applicable ASM performance year.

(A) Significant changes or errors means changes to or errors in a measure that are outside the control of the clinician and its agents and that CMS determines may result in patient harm or misleading results. Significant changes or errors include, but are not limited to the following:

(1) Changes to codes (such as ICD-10, CPT, or HCPCS codes) or the active status of codes.

(2) The inadvertent omission of codes or inclusion of inactive or inaccurate codes.

(3) Changes to clinical guidelines or measure specifications.

(B) CMS publishes a list of all measures scored in a form and manner specified by CMS.

(C) If the data are not available or CMS determines that they may result in patient harm or misleading results, the measure is excluded from an ASM participant's total measure achievement points and total available measure achievement points.

(iii) An ASM participant does not receive a quality ASM performance category score if the ASM participant meets the quality ASM performance category data submission requirements specified at § 512.720(a)(1)(i) but does not meet the case minimum requirements specified in paragraph (g) of this section for any required quality ASM performance category measure specified in paragraphs (b) or (c) of this section, as applicable, that has a benchmark as specified in paragraph (h)(2) of this section.