Maximize Your Results by Starting Early with eCQM and MIPS CQM Reporting

ACOs that are part of the Medicare Shared Savings Program (MSSP) will soon face new reporting obligations as the CMS Web Interface is set to phase out in 2025. Starting from that point, ACOs will be mandated to submit electronic clinical quality measures (eCQMs) or MIPS CQMs. This transition to a novel reporting method carries substantial implications for ACOs. Therefore, it becomes imperative for them to grasp the intricacies of how quality will be reported and assessed. This article aims to provide ACOs with comprehensive insights into the new reporting requirements, emphasizing the advantages of gaining early experience with these measures to enhance reporting outcomes in the future.

ACO Quality Measurement Timeline

CMS is implementing a comprehensive overhaul of quality reporting and measurement for MSSP ACOs. In 2025, the Web Interface reporting option will be retired, necessitating ACOs to adopt the new reporting framework known as the APM Performance Pathway (APP). This updated framework requires ACOs to report either eCQMs or MIPS CQMs. The primary objective behind this change is to enhance patient care quality while aligning ACO quality reporting with the Merit-Based Incentive Payment System (MIPS) of the Quality Payment Program (QPP).


ACOs have the choice to report three quality measures using either eCQMs or MIPS CQMs. eCQMs involve data generated from certified electronic health record (EHR) technology, while MIPS CQMs are calculated and reported through a Qualified Registry. The key distinction between eCQMs and MIPS CQMs lies in the origin of the data.

eCQM Data SourcesCQM Data Sources
QRDA* Category I File (patient-level data)
QRDA* Category III File (aggregated data)
QRDA* Category I File (patient-level data)
QRDA* Category III File (aggregated data)
Billing/Claims Files
CSV, Excel Files
Manual Chart Extraction

ACOs will undergo a transition in their reporting methodology, shifting from a sample-based approach to encompassing the reporting of “all-payer” data. Historically, ACOs reported individual quality measures for a subset of 248 beneficiaries assigned to Medicare through the Web Interface. However, with the adoption of eCQMs or MIPS CQMs, reporting will encompass a wider patient population. ACOs will now need to adhere to new “data completeness” requirements, necessitating reporting for at least 70% of eligible patients, regardless of payer, across all participating clinicians in the ACO, including specialists. By 2024, this threshold will be raised to 75%.

APP Measure Scoring

ACOs will be assigned a score ranging from 3 to 10 points for each measure that fulfills the data completeness and case minimum requirements. The points allotted to an ACO for each measure will be determined by comparing its performance to benchmarks utilized for non-ACO individual and group reporters within the MIPS program. The benchmarks will vary based on the chosen reporting method (eCQMs vs MIPS CQMs).

Starting in 2023, a health equity adjustment will recognize ACOs that report all-payer eCQMs/MIPS CQMs, demonstrate high performance, and cater to a significant proportion of underserved beneficiaries. This adjustment has the potential to award up to 10 bonus points to the ACO’s MIPS quality performance category score.

Quality Performance Standard

CMS has implemented changes to the quality performance standard threshold, which denotes the minimum quality score an ACO must achieve to qualify for shared savings. The performance standard has been set at the 30th percentile of MIPS quality scores for the years 2021 to 2023, and the 40th percentile for 2024 and subsequent years.

Starting from 2023, ACOs that fall below the minimum quality performance standard can still be eligible for shared savings (or be responsible for shared losses) but at a reduced rate if they attain a score at or above the 10th percentile on at least one of the four APP outcome measures. The reduced rates of shared savings or losses will be calculated on a sliding scale, which is linked to the ACO’s quality performance score.

Why Starting Early is Important

Preparing for the upcoming data reporting requirements necessitates careful consideration due to the intricate nature of transitioning to eCQM and MIPS CQM reporting. Accountable Care Organizations (ACOs) will face the task of establishing workflows and infrastructure capable of aggregating data from various sources, such as Tax Identification Numbers (TINs), electronic health record systems (EHRs), billing systems, and clinical data platforms. The aggregation process must account for de-duplication to ensure accurate reporting.

During the voluntary transition period, ACOs are granted valuable time to address challenges related to all-payer data aggregation. This period also presents an opportunity to gain hands-on experience with eCQMs and MIPS CQMs before mandatory reporting commences in 2025. ACOs can utilize this time to evaluate their performance and initiate efforts to enhance their scores. To initiate the eCQM and MIPS CQM reporting journey, ACOs should consider the following five aspects:

  • Who are your eligible patients? ACOs should prioritize identifying their eligible patient population for each quality measure. Conducting a preliminary analysis allows ACOs to focus on TINs with a larger proportion of eligible patients, streamlining their efforts.
  • Where is your data? A thorough assessment of data locations across the ACO is crucial, considering the presence of multiple TINs, EHRs, billing systems, and data platforms. Since reconciling data from diverse resources can be challenging, implementing effective aggregation tools becomes essential.
  • What is your performance? Calculating the number of patients who meet or do not meet the performance criteria for each measure is vital, with a minimum requirement of 70% of eligible patients. Once the data completeness threshold is met, ACOs can assess the approximate performance rate for each measure.
  • When do you report the data? ACOs must collect data for the entire 12-month performance year, spanning from January 1st to December 31st. If ACOs choose to submit data to CMS during the transition period, the submission deadline is March 31st following the end of the performance period.
  • Why should you use the transition period to start early? ACOs must achieve satisfactory performance on the measures to maintain eligibility for shared savings. Understanding the current performance on eCQMs or MIPS CQMs allows ACOs to implement workflow and operational changes necessary for performance improvement. Moreover, CMS grants leeway in scoring on the APP measures for ACOs voluntarily reporting during the transition period.

What Next?

ACOs are facing a limited timeframe to get ready for the mandatory eCQM and MIPS CQM reporting by 2025. To facilitate this preparation, Submit2CMS presents affordable solutions to efficiently aggregate data from various sources, validate data, and track performance. Seizing this opportunity to gain experience now is the optimal approach to guarantee successful reporting in the future. Schedule a meeting with Submit2CMS today to discover how their expertise can assist your ACO in navigating eCQM and CQM reporting seamlessly.