CMS Approves Suppression of the 2022 Performance Period Quality Measure #238: Use of High-Risk Medications in Older Adults for the Clinical Quality Measure (CQM) Collection Type

The Centers for Medicare & Medicaid Services (CMS) published the 2022 Performance Period Suppressed and Truncated MIPS Quality Measures List announcing that quality measure 238: Use of High-Risk Medications in Older Adults will be suppressed for the 2022 performance period within the MIPS CQM collection type.

During the annual measure revision process, a second submission criteria was added to the measure. As part of the revision, the Quality Data Codes (QDCs) utilized for Performance Met (G9367) and Performance Not Met (G9368) in Submission Criteria 1 were also included as QDCs for Performance Met and Performance Not Met Numerator Options in Submission Criteria 2, which makes it difficult to differentiate which quality action should be attributed to each submission criteria. As a result, when these specific QDCs are submitted, it isn’t known which submission criteria the specific QDCs are applicable to or if each quality action was met. Due to this error, it isn’t possible to accurately assess numerator compliance.

CMS determined that this measure has undergone a substantive change that may result in misleading results, due to the inability to accurately delineate the quality action for each submission criteria. Clinicians, groups, and/or virtual groups won’t be able to correctly document quality actions for the 2022 performance period and would be unable to identify the applicable numerator option for each submission criteria. Therefore, this measure will be suppressed within the MIPS CQM collection type for the 2022 performance period, in accordance with § 414.1380(b)(1)(vii)(A). The electronic clinical quality measure (eCQM) collection type wasn’t impacted by this revision and won’t be suppressed for the 2022 performance period.

MIPS-eligible clinicians, groups, and virtual groups won’t need to submit any additional documentation as the measure will be excluded from scoring (denominator reduced by 10 points) for this measure, if submitted. As a reminder, all measures—including suppressed or truncated measures—must meet data completeness and case minimum criteria.

For further information regarding measure suppression, please review the 2022 Traditional MIPS Scoring Guide and the 2022 MIPS Historical Quality Benchmarks File in the 2022 Quality Benchmarks. Submission and scoring examples have been added to pages 25-27 of the 2022 Traditional MIPS Scoring Guide and updated in Appendix D to reflect all suppressed and truncated measures. Please note that CMS is working to update the submission system to reflect the suppression of quality measure 238; the agency anticipates this will be completed in the next 2 weeks.