Appendix F 2023 Peer Reviewed Journal Article Requirement Template

2023 MIPS Peer-Reviewed Journal Article Requirement Template
Section 101(c)(1) of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires
submission of new measures for publication in applicable specialty-appropriate, peer-reviewed journals prior to
implementing in the Merit-based Incentive Payment System (MIPS). These measures will be submitted by the
Centers for Medicare & Medicaid Services (CMS), to a journal(s), before including any new measure in the
MIPS Quality Measures List under MIPS. The measure submitter shall provide the required information for
article submission under the MACRA per the CMS Call for MIPS Quality Measures submission process.
Stakeholders submitting measures to the MIPS Call for Quality Measures must complete the required
information by the Annual Call for Measures deadline. Some of the information requested below may be listed
in specific fields in the Measures Under Consideration (MUC) Entry/Review Information Tool (MERIT);
however, to ensure that CMS has all of the necessary information and to avoid delays in the evaluation of your
submission, please fully complete this form as an attached Word document. The information in MERIT must be
consistent with the information below, which includes the following, but is not limited to:
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•

[Measure Title]
[Meaningful Measures 2.0 Framework Domain]

Measure Steward: [Name]
Measure Developer: [Name]
Description: [Text]
I.

Statement
• Background (Why is this measure important?).
• Environmental scan (Are there existing measures in this area?).

II.

Gap Analysis
• Provide evidence for the measure (What are the gaps and opportunities to improve care?).
• Expected outcome (patient care/patient health improvements, cost savings).
• Recommendation for the measure (Is it based on a study, consensus opinion, USPSTF
recommendation etc.?).

III.

Reliability/Validity
• What testing has been performed at the level of implementation? (MIPS requires full measure
testing at the individual clinician level (and may also need to be tested at the group level) for
MIPS Clinical Quality Measures (CQMs) and Electronic Clinical Quality Measures (eCQMs)
collection types. Administrative claims measures tested at the group level require a reliability
threshold to be implemented at the group level.)
Please provide testing results including the N value, Bonnie test case results, correlation
coefficient and any other pertinent information or values to be considered.
o
o
o
o
o
o
•

Reliability Testing Results at the accountable entity level
Face Validity Testing Results, Clinician Sites
Empiric Validity Testing Results at the accountable entity level
Data Element/Patient Encounter Level Testing
Exclusion Frequency
What were the minimum sample sizes used for reliability results?

Other Information
o Is it risk adjusted? If so, how?
o What benchmarking information is available?
o Collection Type: Specify the data collection type.

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o
o

Specify measure stage of development.
For Patient Reported Outcome Performance Measures:
- The survey or tool has been tested and does not require modifications based on
results?
- Patient/encounter level testing for each critical data element does not require
changes to the tool base on the results?

IV.

Endorsement
• Provide the Consensus-Based Entity (CBE) endorsement status (i.e., National Quality Forum
(NQF)) (and CBE ID) and/or other endorsing body (If the measure is only endorsed for paper
records, please note endorsement for only the data source being submitted.).

V.

Summary
• Alignment with CMS Meaningful Measures Initiative or MACRA (if applicable).
• Relevance to MIPS or other CMS programs.
• Rationale: Use of measure for inclusion in program (specialty society, regional collaborative,
other).
• Public reporting (if applicable).
• Preferable relevant peer-reviewed journal for publication.
• Rationale as to how the measure correlates to existing cost measures and improvement
activities, as applicable and feasible.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
valid OMB control number. The valid OMB control number for this information collection is 0938-1314 (Expiration date: 01/31/2025).
The time required to complete this information collection is estimated to average 2 hours per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have
comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security
Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please
do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports
Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the
associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns
regarding where to submit your documents, please contact QPP at qpp@cms.hhs.gov.

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