Receiving PI Score Even With No Base Measures

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Randal Roe (Alpha II Registry)

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Dec 7, 2018, 9:31:09 AM12/7/18
to Developer Group for QPP APIs
As part of our API testing, we submitted five PI measures. None of them are base score measures, so we expected a PI score of zero. Also, we did not submit any of the attestation measures, so that is one more reason why we expected a PI score of zero.

However, we received back a PI score of 15, which was then weighted to 3.75 for the MIPS overall score. (15 points * 25% weighting = 3.75 points.)

The 15 PI points were from the performance portion: 10 points for PI_PHCDRR_4 and 5 points for PI_PHCDRR_5_MULTI. I’ve attached three files that show this:
  • 01_PI Submission.txt: the five PI measures we submitted via the API
  • 02_PI Response.txt: acknowledgment of what we submitted
  • 03_Score.txt: scoring results
I’ve copied the contents of 03_Score.txt below and highlighted the lines that we’ve been focusing on. Are we missing something? Or is this an issue with the Submission API?

A somewhat-related question: With these “Public Health and Clinical Data Registry Reporting” measures, shouldn’t the first one go to the performance score (10 points) and the second one to the bonus score (5 points)?

Thank you.

Randal Roe
Alpha II Registry


{
  "data": {
    "score": {
      "name": "total",
      "title": "Total Score",
      "detail": "0.50.1",
      "value": 3.75,
      "parts": [
        {
          "name": "ia",
          "title": "IA component of total score",
          "detail": "Scoring based on weight of 15%.",
          "value": 0,
          "original": {
            "name": "ia",
            "value": 0,
            "detail": "Picked the highest scoring measurement set webAttestation",
            "parts": [
              {
                "name": "ia",
                "value": 0,
                "title": "Improvement Activities Score",
                "detail": "webAttestation",
                "parts": [],
                "metadata": {
                  "messages": {},
                  "maxContribution": 40,
                  "measurementSetId": "fabricated-ia-1",
                  "measurementSetPicked": true
                }
              }
            ]
          },
          "metadata": {
            "unroundedScoreValue": 0,
            "maxContribution": 15
          }
        },
        {
          "name": "pi",
          "title": "PI component of total score",
          "detail": "Scoring based on weight of 25%.",
          "value": 3.75,
          "original": {
            "name": "pi",
            "value": 15,
            "detail": "Picked the highest scoring measurement set registry",
            "parts": [
              {
                "name": "pi",
                "title": "Promoting Interoperability Score",
                "value": 15,
                "detail": "registry",
                "parts": [
                  {
                    "name": "pi_base",
                    "metadata": {
                      "maxContribution": 100,
                      "unroundedScoreValue": 0
                    },
                    "value": 0,
                    "detail": "",
                    "parts": [],
                    "warnings": []
                  },
                  {
                    "name": "pi_performance",
                    "metadata": {
                      "maxContribution": 100,
                      "unroundedScoreValue": 15
                    },
                    "value": 15,
                    "detail": "",
                    "parts": [
                      {
                        "name": "PI_PHCDRR_1_MULTI",
                        "value": 0,
                        "metadata": {
                          "measurementId": "0365c352-1092-4c73-b611-01ecea330137",
                          "maxContribution": 5,
                          "processingStatus": "PICKED",
                          "messages": {
                            "measurementPicker": "Measurement does not have a submitted peer. Picked. Measure is complete and weight is greater than 0."
                          }
                        }
                      },
                      {
                        "name": "PI_PHCDRR_2_MULTI",
                        "value": 0,
                        "metadata": {
                          "measurementId": "0365c352-181e-4917-8019-a8a039a48e70",
                          "maxContribution": 5,
                          "processingStatus": "PICKED",
                          "messages": {
                            "measurementPicker": "Measurement does not have a submitted peer. Picked. Measure is complete and weight is greater than 0."
                          }
                        }
                      },
                      {
                        "name": "PI_PHCDRR_3_MULTI",
                        "value": 0,
                        "metadata": {
                          "measurementId": "0365c352-1044-4145-80ab-f9e100e261d2",
                          "maxContribution": 5,
                          "processingStatus": "PICKED",
                          "messages": {
                            "measurementPicker": "Measurement does not have a submitted peer. Picked. Measure is complete and weight is greater than 0."
                          }
                        }
                      },
                      {
                        "name": "PI_PHCDRR_4",
                        "value": 10,
                        "metadata": {
                          "measurementId": "0365c352-1b5f-4936-85d0-3bf29ce3039e",
                          "maxContribution": 10,
                          "processingStatus": "PICKED",
                          "messages": {
                            "measurementPicker": "Measurement does not have a submitted peer. Picked. Measure is complete and weight is greater than 0."
                          }
                        }
                      },
                      {
                        "name": "PI_PHCDRR_5_MULTI",
                        "value": 5,
                        "metadata": {
                          "measurementId": "0365c352-12f6-4e60-9b3c-c5684760a44f",
                          "maxContribution": 5,
                          "processingStatus": "PICKED",
                          "messages": {
                            "measurementPicker": "Measurement does not have a submitted peer. Picked. Measure is complete and weight is greater than 0."
                          }
                        }
                      }
                    ],
                    "warnings": []
                  },
                  {
                    "name": "pi_bonus",
                    "metadata": {
                      "maxContribution": 100,
                      "unroundedScoreValue": 0
                    },
                    "value": 0,
                    "detail": "",
                    "parts": [],
                    "warnings": []
                  },
                  {
                    "name": "cehrt_bonus",
                    "metadata": {
                      "maxContribution": 100,
                      "unroundedScoreValue": 0
                    },
                    "value": 0,
                    "detail": "",
                    "parts": [],
                    "warnings": []
                  }
                ],
                "metadata": {
                  "messages": {
                    "attestationStatementCheck": "Attestation Statements are complete",
                    "baseMeasureCheck": "Base measures are incomplete",
                    "attestationBonusEligible": "Attestation Statements, Base measures, or Performance Period checks are not complete. Not eligible for attestation bonus.",
                    "registryPerformanceBonus": "[PI_PHCDRR_4] Registry performance bonus measure found. 10 point bonus awarded.",
                    "registryBonus": "[PI_PHCDRR_5_MULTI] Registry bonus measure found. 5 point bonus awarded."
                  },
                  "measuresPicked": [
                    "PI_PHCDRR_1_MULTI",
                    "PI_PHCDRR_2_MULTI",
                    "PI_PHCDRR_3_MULTI",
                    "PI_PHCDRR_4",
                    "PI_PHCDRR_5_MULTI"
                  ],
                  "measuresSkipped": [],
                  "maxContribution": 100,
                  "measurementSetId": "0365c352-f5b3-40c9-bc95-015584cd2f82",
                  "unroundedScoreValue": 15,
                  "measurementSetPicked": true
                },
                "warnings": []
              }
            ],
            "warnings": [],
            "metadata": {
              "unroundedScoreValue": 15
            }
          },
          "metadata": {
            "unroundedScoreValue": 3.75,
            "maxContribution": 25
          }
        }
      ],
      "metadata": {
        "messages": {},
        "maxTotalScore": 100,
        "maxHighContributionIA": 20,
        "maxMediumContributionIA": 10,
        "maxContributionIA": 15,
        "maxContributionACI": 25,
        "maxContributionQuality": 50,
        "maxContributionCost": 10,
        "instrumentation": {
          "isSubmissionFabricated": false,
          "hasIAMeasures": false,
          "hasQualityMeasures": false,
          "hasACIMeasures": false,
          "hasPIMeasures": true,
          "hasCostMeasures": false,
          "hasACRMeasure": false,
          "hasCAHPSMeasure": false,
          "hasScorableIAMeasures": false,
          "hasScorableACIMeasures": false,
          "hasScorablePIMeasures": true,
          "hasScorableCostMeasures": false,
          "hasScorableQualityMeasures": false,
          "hasSkippedWIMSet": false,
          "hasMergedRegistryMSet": false,
          "givenIAStudyCredit": false,
          "hasIAWeightStatus": "NORMAL",
          "givenAPMParticipationCredit": false,
          "givenIACreditPCMH": false,
          "hasMinimumACIPerformancePeriod": false,
          "hasMinimumPIPerformancePeriod": true,
          "reasonCodes": []
        },
        "unroundedScoreValue": 3.75
      },
      "warnings": [
        "Disclaimer: Scoring is subject to change, based on periodic policy updates, eligibility reviews, and technical integration developments."
      ],
      "errors": []
    }
  }
}

01_PI Submission.txt
02_PI Response.txt
03_Score.txt

Steve Szeliga

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Dec 7, 2018, 4:30:11 PM12/7/18
to Developer Group for QPP APIs
Good Afternoon! 

I was unable to reproduce this issue, please try your submission again and let me know if you are still seeing the same behavior. 
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