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

Submitting Medicare CQM Data: Your Role

CCACO makes it easy to participate in quality reporting. Here’s how your practice contributes in 3 simple steps:

  • Pull Your Registry Report
    Download the eCQM registry report from your EHR. Includes required data like Patient Name, DOB, NPI, and measure results.
  • Upload to Our Portal
    Log in to the CCACO Quality Portal, upload your report securely (HTTPS-encrypted). No formatting changes needed — just drop in the file.
  • Review Flagged Patients
    You’ll be notified if any patients are missing required data or are non-compliant. These flagged patients will need manual entry using our portal.
What Happens Behind the Scenes
  • We validate and merge your data with claims
  • Measure scores are calculated and attributed to your practice
  • Final files are submitted to CMS
View Step-by-Step PDF Instructions
View Full Screen

Measures Reported by CCACO (2025)

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

  1. CMS122v13 – Diabetes: Glycemic Status Assessment Greater than 9%
    Previously: Diabetes: Hemoglobin A1c Poor Control
    Description: % of patients 18–75 with diabetes whose most recent HbA1c is > 9%.
    Numerator: Most recent HbA1c > 9%. (CPT: 83036)
    Goal: Lower is better — < 9% indicates control.
  2. CMS165 – Controlling High Blood Pressure (Quality ID 236)
    Description: % of patients 18–85 with a diagnosis of hypertension whose blood pressure was adequately controlled (<140/90 mmHg) during the measurement period.
    Numerator: Most recent blood pressure reading <140/90 mmHg.
    Goal: Higher is better — indicates better blood pressure control.
  3. CMS2v14 – Preventive Care and Screening: Screening for Depression and Follow-Up Plan
    Previously: Depression Screening with Follow-Up
    Description: % of patients 12+ screened for depression with a documented follow-up plan.
    Exclusions: Patients with an existing depression diagnosis.
    Goal: Early detection and intervention.
  4. CMS125v13 – Breast Cancer Screening
    Description: % of women 50–74 who had a mammogram.
    Goal: Screening every 1–2 years.

What’s Coming Next? – Future Measure Additions

As part of CMS’s phased implementation of the APP Plus measure set, the following measures are expected in future performance years:

2026 (Proposed)
  • Colorectal Cancer Screening:
    % of adults 50–75 who received appropriate colorectal cancer screening.
  • Statin Therapy for Cardiovascular Disease:
    % of patients with CVD who were prescribed statin therapy.
2027 (Planned)
  • Follow-Up After ED Visit for High-Risk Chronic Conditions:
    % of discharges from the ED with a follow-up visit within 7 days for patients with chronic conditions.
  • Social Drivers of Health Screening:
    % of patients screened for food insecurity, housing instability, transportation access, utility needs, and interpersonal safety.
  • Advance Care Planning:
    % of patients with documentation of advance care planning conversations and preferences.
2028+
  • Full eCQM Transition:
    CMS expects all ACOs to submit via eCQMs only, using all-payer data and standardized electronic formats with increased interoperability.

Source: CMS 2025 Final Rule

Need Assistance?

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