Quality Reporting FAQ

What's Changing in 2025?

Beginning with Performance Year (PY) 2025, CMS is retiring the MIPS CQM pathway for ACOs. All ACOs will instead report quality through one of two collection types under the APP:

  • eCQMs (electronic Clinical Quality Measures) – requires all-payer data from certified EHRs
  • Medicare CQMs – previously called MIPS CQM; uses Medicare-only patient population

This shift encourages integration of quality reporting into clinical workflows and will impact how practices prepare, extract, and submit patient data. CMS has set a glide path for this transition, with Medicare CQM remaining available through at least 2026 before full eCQM adoption is likely required.


Transition to the APP Plus Quality Measure Set

CMS finalized a streamlined APP Plus set that applies to all Shared Savings Program ACOs starting in PY2025. The measure set includes core chronic condition and prevention-related quality metrics. This new approach emphasizes simplicity, comparability, and alignment across reporting platforms.


What’s New for Providers?

  • Web Interface reporting is fully sunset — no ACOs will report using that format starting 2025
  • All practices will contribute to either eCQM or Medicare CQM submission through CCACO
  • Data must reflect patients seen by each provider — not just those with Medicare
  • Measures will be scored collectively across the ACO, with benchmarks based on performance rates

Overview of Reporting Methods

Feature eCQMs Medicare CQMs
Data Source Certified EHRs (all-payer data) EHR, registry, or manual entry (Medicare-only)
Submission Via EHR or data aggregator Via web platform or registry
Automation Level Mostly automated May require manual abstraction
Data Format Standardized (QRDA I) Flexible templates / CSVs
Population All payers Medicare only

How We’re Collecting Data

CCACO will be submitting our quality measures under the Medicare CQM pathway for the 2025 performance year (formerly known as MIPS CQM). Our priority is to leverage all available data sources before requesting manual entry from practices. This means we will:

  • Primary Method: Practices will submit Medicare CQM data using our secure web reporting platform. This includes downloadable templates and detailed chart review to supplement all remaining data gaps.
  • eCQM Supplementation: For practices using EHRs capable of exporting eCQMs (QRDA I), we will extract and incorporate those files to improve completeness.

Manual Reporting via CCACO Web Portal (Workflow Example)

Practices submitting data manually through our web portal should follow these steps:

  1. Log in to https://www.ccaco.org/login with your provided credentials
  2. Click “Medicare CQMs” in the sidebar
  3. Select the provider you will be reporting for
  4. Complete each measure for eligible patients

View step-by-step PDF instructions below:

View Full Screen

Measures Reported by CCACO (2025)

These are the core measures CCACO is reporting for 2025 under the APP Plus framework:

  1. Diabetes: Hemoglobin A1c Poor Control
    Description: % of patients 18–75 with diabetes whose HbA1c is > 9%.
    Numerator: Most recent HbA1c > 9%. (CPT: 83036)
    Goal: Lower is better — < 9% indicates control.
  2. High Blood Pressure Screening with Follow-Up
    Description: % of adults screened for BP with a follow-up plan if elevated.
    Exclusions: Patients already diagnosed with hypertension.
    Goal: BP maintained below 140/90 mmHg.
  3. Depression Screening with Follow-Up
    Description: % of patients 12+ screened for depression + follow-up plan.
    Exclusions: Patients with documented diagnosis.
    Goal: Early detection and intervention.
  4. Breast Cancer Screening
    Description: % of women 50–74 who had a mammogram.
    Goal: Screening every 1–2 years.

Need Assistance?

For questions, contact ghu@ccaco.org or call 212-965-0222.