{
"data": {
"score": {
"name": "total",
"title": "Total Score",
"detail": "0.57.4",
"value": "12.8799999999999990.00",
"parts": [
{
"name": "quality",
"title": "QUALITY component of total score",
"detail": "Scoring based on weight of 50%.",
"value": 7.88,
"original": {
"name": "quality",
"value": 15.8,
"detail": "Picked the highest scoring measurement set registry",
"parts": [
{
"name": "quality",
"value": 15.8,
"detail": "registry",
"parts": [
{
"name": "236",
"value": 4.6,
"detail": "Contributing 4.6",
"instrumentations": [
{
"reasonCode": "QUALITY-009",
"message": "Measurement meets the minimum reporting rate for this attestation year."
},
{
"reasonCode": "QUALITY-051",
"message": "Measure is a class 1 measure, Eligible population is >= 20 and reporting rate > 60 and has benchmarks"
},
{
"reasonCode": "QUALITY-078",
"message": "Applied default decile scoring."
},
{
"reasonCode": "QUALITY-091",
"message": "Class 1 measures receive a higher weight than the rest."
},
{
"reasonCode": "QUALITY-096",
"message": "If measure is end to end reported, then end to end bonus score is applied."
},
{
"reasonCode": "QUALITY-111",
"message": "Measure contributed points to total score."
},
{
"reasonCode": "QUALITY-113",
"message": "Measure contributed bonus points to total score."
},
{
"reasonCode": "QUALITY-117",
"message": "Measurement points for PICKED measure include decile score with all bonus points."
},
{
"reasonCode": "QUALITY-006",
"message": "If submission type is registry with 'isEndToEndReported' or measure is a eCQM, override benchmarks with EHR"
}
],
"metadata": {
"performanceRate": 54.28,
"reportingRate": 100,
"measurementSetId": "03e856b7-6ae6-4ff8-a7bb-3d6201a8ea2c",
"measurementId": "03e856b7-49f4-4dae-b105-68a5106e098a",
"measureClass": "Class 1",
"measureTitle": "Controlling High Blood Pressure",
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"endToEndBonusEligible": true,
"endToEndBonus": 1,
"outcomeOrPatientExperienceBonus": 0,
"highPriorityBonus": 0,
"highPriorityBonusIgnored": true,
"decileScore": 3.59,
"performanceDenominator": 3303,
"performanceNumerator": 1793,
"eligiblePopulation": 3377,
"partialDecileScore": 0.6,
"partialPoints": 3.18,
"decile": 3,
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0,
51.1,
56.52,
60.78,
64.29,
67.47,
70.94,
74.89,
80.43
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"processingStatus": "PICKED",
"totalMeasurementPoints": 4.59,
"totalBonusPoints": 1,
"messages": {
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"measurementClass": "Eligible population is greater than or equal to 20, reporting rate is greater than 60% and has benchmarks",
"e2eBonusScore": "Bonus from isEndToEndReported",
"highPriorityBonus": "Measure having highest decile score (preference given to outcome, intermediate outcome, intermediate outcome and process) is not eligible for high priority bonus",
"measurementPicker": "Picked at 1",
"totalMeasurementPoints": "Measurement points for PICKED measure include decile score with all bonus points"
},
"noBenchmarks": false,
"benchmarkType": "electronicHealthRecord",
"eMeasureId": "CMS165v6",
"cpcPlusGroup": "Outcome_Measure",
"toppedOut": false,
"isGhost": false,
"unroundedScoreValue": 4.59
}
},
{
"name": "113",
"value": 4.9,
"detail": "Contributing 4.9",
"instrumentations": [
{
"reasonCode": "QUALITY-009",
"message": "Measurement meets the minimum reporting rate for this attestation year."
},
{
"reasonCode": "QUALITY-051",
"message": "Measure is a class 1 measure, Eligible population is >= 20 and reporting rate > 60 and has benchmarks"
},
{
"reasonCode": "QUALITY-078",
"message": "Applied default decile scoring."
},
{
"reasonCode": "QUALITY-091",
"message": "Class 1 measures receive a higher weight than the rest."
},
{
"reasonCode": "QUALITY-096",
"message": "If measure is end to end reported, then end to end bonus score is applied."
},
{
"reasonCode": "QUALITY-105",
"message": "Measure eligible for high priority bonus with minimum performance rate and eligible populations reached."
},
{
"reasonCode": "QUALITY-111",
"message": "Measure contributed points to total score."
},
{
"reasonCode": "QUALITY-113",
"message": "Measure contributed bonus points to total score."
},
{
"reasonCode": "QUALITY-117",
"message": "Measurement points for PICKED measure include decile score with all bonus points."
},
{
"reasonCode": "QUALITY-005",
"message": "If measure is found to be in a clinical cluster the measure will be labeled with its EMA relationship"
},
{
"reasonCode": "QUALITY-006",
"message": "If submission type is registry with 'isEndToEndReported' or measure is a eCQM, override benchmarks with EHR"
}
],
"metadata": {
"performanceRate": 22.42,
"reportingRate": 100,
"measurementSetId": "03e856b7-6ae6-4ff8-a7bb-3d6201a8ea2c",
"measurementId": "03e856b7-40d3-46d4-9167-3893050cef64",
"measureClass": "Class 1",
"measureTitle": "Colorectal Cancer Screening",
"highPriorityBonusEligible": false,
"endToEndBonusEligible": true,
"endToEndBonus": 1,
"outcomeOrPatientExperienceBonus": 0,
"highPriorityBonus": 0,
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"performanceDenominator": 2899,
"performanceNumerator": 650,
"eligiblePopulation": 3053,
"partialDecileScore": 0.9,
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"decile": 3,
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0,
12.61,
23.92,
34.32,
44.55,
54.1,
63.64,
73.1,
83.15
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"processingStatus": "PICKED",
"totalMeasurementPoints": 4.87,
"totalBonusPoints": 1,
"messages": {
"benchmarkType": "Override registry benchmark with eHR benchmark as isEndToEndReported is true",
"measurementClass": "Eligible population is greater than or equal to 20, reporting rate is greater than 60% and has benchmarks",
"e2eBonusScore": "Bonus from isEndToEndReported",
"measurementPicker": "Picked at 2",
"totalMeasurementPoints": "Measurement points for PICKED measure include decile score with all bonus points"
},
"noBenchmarks": false,
"benchmarkType": "electronicHealthRecord",
"eMeasureId": "CMS130v6",
"cpcPlusGroup": "Other_Measure",
"toppedOut": false,
"isGhost": false,
"emaEligibilityScenarios": {
"ehrBenchmarkInUse": true
},
"unroundedScoreValue": 4.87
}
}
],
"instrumentations": [
{
"reasonCode": "QUALITY-031",
"message": "EMA eligible specialty sets have between one and five EMA eligible measures"
},
{
"reasonCode": "QUALITY-032",
"message": "EMA eligible specialty sets do not contain QCDR measurements"
},
{
"reasonCode": "QUALITY-124",
"message": "If EHR benchmark replacement was used, then measurement set is disqualified as EMA specialty set"
},
{
"reasonCode": "QUALITY-025",
"message": "EMA eligible clinical clusters have between one and five EMA eligible measures"
},
{
"reasonCode": "QUALITY-026",
"message": "EMA eligible clinical clusters do not contain QCDR measurements"
},
{
"reasonCode": "QUALITY-127",
"message": "If EHR benchmark replacement was used, then measurement set is disqualified as EMA clinical cluster for registry measurement sets"
},
{
"reasonCode": "QUALITY-071",
"message": "At least 1 high or outcome or patient experience measure available, so denominator is 60."
},
{
"reasonCode": "QUALITY-100",
"message": "Measure having highest decile score (preference given to outcome, intermediate outcome, intermediate outcome and process) is not eligible for high priority bonus."
},
{
"reasonCode": "QUALITY-116",
"message": "Applicable measurement points summed."
}
],
"metadata": {
"messages": {
"denominator": "At least 1 high or outcome or patient experience measure available. So denominator is 60",
"totalDecileScore": "Decile score points for measurements included in measurement set score, excluding bonus points",
"totalBonusPoints": "Sum of measurement bonus points included in the measurement set score",
"totalMeasurementPoints": "Sum of applicable measurement points."
},
"measurementSetId": "03e856b7-6ae6-4ff8-a7bb-3d6201a8ea2c",
"maxContribution": 100,
"measuresPicked": [
"236",
"113"
],
"measuresSubmittedCount": 2,
"measuresSubmitted": [
"236",
"113"
],
"totalDecileScore": 7.5,
"totalBonusPoints": 2,
"totalMeasurementPoints": 9.5,
"denominator": 60,
"e2eBonusScore": 2,
"maxMeasurementsAllowed": 6,
"mergedWithCahps": false,
"processingStatus": "PICKED",
"unroundedScoreValue": 9.46,
"measurementSetPicked": true,
"reweightedScore": 9.5
}
}
],
"metadata": {
"unroundedScoreValue": 15.766666666666667
},
"instrumentations": [
{
"reasonCode": "QUALITY-031",
"message": "EMA eligible specialty sets have between one and five EMA eligible measures"
},
{
"reasonCode": "QUALITY-032",
"message": "EMA eligible specialty sets do not contain QCDR measurements"
},
{
"reasonCode": "QUALITY-124",
"message": "If EHR benchmark replacement was used, then measurement set is disqualified as EMA specialty set"
},
{
"reasonCode": "QUALITY-025",
"message": "EMA eligible clinical clusters have between one and five EMA eligible measures"
},
{
"reasonCode": "QUALITY-026",
"message": "EMA eligible clinical clusters do not contain QCDR measurements"
},
{
"reasonCode": "QUALITY-127",
"message": "If EHR benchmark replacement was used, then measurement set is disqualified as EMA clinical cluster for registry measurement sets"
},
{
"reasonCode": "QUALITY-071",
"message": "At least 1 high or outcome or patient experience measure available, so denominator is 60."
},
{
"reasonCode": "QUALITY-100",
"message": "Measure having highest decile score (preference given to outcome, intermediate outcome, intermediate outcome and process) is not eligible for high priority bonus."
},
{
"reasonCode": "QUALITY-116",
"message": "Applicable measurement points summed."
}
]
},
"metadata": {
"maxContribution": 50,
"unroundedScoreValue": 7.883333333333334
}
},
{
"name": "feedback-quality",
"parts": [
{
"name": "236",
"detail": "Focus on improving measure 236"
},
{
"name": "113",
"detail": "Focus on improving measure 113"
}
]
},
{
"name": "bonuses",
"value": 5,
"parts": [
{
"name": "smallPractice",
"value": 5
}
]
}
],
"instrumentations": [],
"metadata": {
"messages": {
"smallPracticeBonus": "5 point bonus applied for small practice",
"complexPatientBonus": "0.00 point bonus applied for complex patient bonus",
"maxComplexPatientBonus": "5 point maximum for complex patient bonus"
},
"maxTotalScore": 100,
"maxHighContributionIA": 40,
"maxMediumContributionIA": 20,
"maxContributionIA": 15,
"maxContributionQuality": 50,
"maxContributionCost": 10,
"maxContributionPI": 25,
"piRollupBonus": 0,
"iaCategoryScore": 0,
"iaWeightedScore": 0,
"iaCategoryScoreUnrounded": 0,
"qualityCategoryScore": 15.8,
"qualityWeightedScore": 7.88,
"qualityCategoryScoreUnrounded": 15.8,
"isSubmissionFabricated": false,
"hasIAMeasures": false,
"hasQualityMeasures": true,
"hasACIMeasures": false,
"hasPIMeasures": false,
"hasCostMeasures": false,
"hasACRMeasure": false,
"hasCAHPSMeasure": false,
"hasScorableIAMeasures": false,
"hasScorableACIMeasures": false,
"hasScorablePIMeasures": false,
"hasScorableCostMeasures": false,
"hasScorableQualityMeasures": true,
"hasSkippedWIMSet": false,
"hasMergedRegistryMSet": false,
"givenIAStudyCredit": false,
"hasIAWeightStatus": "SPECIAL",
"givenAPMParticipationCredit": false,
"givenIACreditPCMH": false,
"hasMinimumACIPerformancePeriod": false,
"hasMinimumPIPerformancePeriod": false,
"hasIncompleteAPMWISubmission": false,
"unroundedScoreValue": 7.883333333333334,
"smallPracticeBonus": 5,
"complexPatientBonus": "0.00",
"maxComplexPatientBonus": 5
},
"warnings": [
"Disclaimer: Scoring is subject to change, based on periodic policy updates, eligibility reviews, and technical integration developments."
],
"errors": []
}
}
}