Traditional MIPS is the foundational reporting pathway for MIPS-eligible clinicians, evaluating performance across four key categories: Quality, Improvement Activities, Promoting Interoperability, and Cost.
Ezderm tracks for 2 out of the 4 MIPS Categories: Quality and Promoting Interoperability.
You can find more information regarding traditional MIPS reporting from the official CMS website linked here: [link]
Quality Category Scoring:
The reporting period is the full calendar year
Data completeness is 75% in 2026
Need to report 6 measures with 1 being an Outcome or High Priority Measure
To view the Quality report within Ezderm login to a provider or admin's account on the EHR > Settings > My profile > MACRA, Quality > click the plus sign in the upper right-hand corner to choose the provider and date range. Once in the report, you can view all measures that Ezderm tracks for and the current score for each.
Questions for each measure within the Quality wizard (Progress Note > MACRA > Quality) are divided into Denominator questions and Numerator questions.
Only if a measure satisfies the Denominator criteria (based on the answers) will it be reported in the Quality report. Each measure has several conditions for meeting the Denominator criteria. In our system, for some measures, these criteria are automatically satisfied (e.g. measure 47), but for some measures, the user needs to answer questions. If the answers follow the Denominator requirements, the visit will be reported (e.g. measure 410).
Let's look at an example with measure 410. In order to get a visit in the Denominator, the patient has to have Psoriasis Vulgaris (or other Dx that satisfies the Denominator criteria), has to have one of the E&M codes (we always predefine this type of question with YES, as the purpose of this question is to prove that you had a face-to-face encounter), and to be treated with systemic or biologic medication for at least six months. Only if you report Yes on all three questions will the measure be eligible, as you satisfied the Denominator criteria. If the patient has Psoriasis Vulgaris and thus 410 is available on the encounter, but you reported No on the biologics question, that visit won't have an influence on your Performance Rate and Reporting Rate. Each denominator question in the Quality wizard is marked as "Denominator Criteria" in the question's description.
Performance Rate is the most important value since your MIPS score for Quality directly depends on it.
Performance Rate = all visits that met the criteria / (patients that have completed visits - patients that were excluded)
For easier comprehension of this formula, you need to know that a visit that passed the Denominator criteria could be categorized as "Met," "Not Met," "Incomplete," or "Exclusion" (exclusion is not available for all measures). Each measure can be reported only as one of these (M/NM/E/I), and whether it is met/not met/exclusion/incomplete depends on your answers. The visit is incomplete if you have not finished a wizard in the Numerator part (e.g. you left the last question unanswered).
The ultimate goal of the eligible clinician is to have as many visits that MET the criteria as possible, and as few visits that did not meet the criteria as possible, since these directly increase and decrease Performance Rate. Based on your Performance Rate and the benchmark CMS provided for that measure, you'll earn from 3 to 10 points each.
An example: Let's say you have 80 patients that satisfied the Denominator criteria for #265. From these 80 patients, 40 patients MET the criteria, 10 reported as exclusion, 10 are incomplete and 20 patients were reported as NOT MET. Your performance rate will be calculated as 40/(70-10) = 0.6667. Since this rate is measured in percentage, your rate is 66.67%. Now, for #265 with this performance rate, you'll be in Decile 4 (based on CMS benchmark), so it means that you'll earn between 4 and 5 points. Benchmark for each measure is different and some measures don't have it. Those will give you 3 points at all, no matter what is your Performance Rate (e.g. 410 and 440). This is just for now, as CMS could provide a benchmark later on. As a side note: If you report less than 20 visits for some measure, you'll also earn 3 points out of 10 if you have at least one measure as MET.
Reporting Rate has to be above 75% (CMS requirement). If satisfied, the value of this rate is not important for the final score, as it just has to be greater than 75% as a proof that you reported for at least 75% of eligible patients. If you have it at 76% or 100%, it would be counted the same.
Reporting Rate = (MET + NOT MET + Exclusions) / visits that passed the Denominator part. In the example given above for #265, your Reporting Rate would be (40+20+10)/80=0.875, and this rate is also measured in percentage, so it would be captured at 87.50%.
Promoting Interoperability
Promoting Interoperability makes up 25% of your MIPS final score. This category includes multiple measures that are organized under 4 objectives. The reporting period is 90 continuous days, so your office will want to select a 90 day period where you will complete the following measures.
Promoting Interoperability Scoring Method:
Measure 1: Protect Patient Health Information
Clinicians must attest "Yes" to conducting or reviewing a security risk analysis and implementing security updates as necessary.
This can be performed via https://www.hipaasecurenow.com/
Measure 2: E-Prescribing
Measure 3: Provider to Patient Exchange
Measure 4: Health Information Exchange
Measure 5: Public Health and Clinical Data Exchange
Your office should reach out to your state registry to set up a connection (this occurs outside of Ezderm). Once you are enrolled with a registry, you can use Ezderm to document the details that are required in the cancer report. After this report is finished and reviewed, it can be generated and uploaded to the Registry.
The process differs from state-to-state, but the general workflow is defined with the following steps:
1. Clinician registers in the Cancer Registry for MU3/MIPS program. Registration is done on Registry end and it is important that registration is completed within 60 days after the start of the MIPS performance period.
2. After completed registration, clinician sends test messages (created through Ezderm) that should be validated by the Registry.
3. Once the Registry finishes validation, production is ready to be started.
*Additional Resources:
CMS: Exploring PI Measures
https://qpp.cms.gov/reporting-requirements/ways-to-report/traditional-mips/promoting-interoperability
Improvement Activities
In 2026, the Improvement Activity performance category counts for 15% of your MIPS final score.
To earn full credit in this performance category, you must generally submit the following:
Those with the small practice, rural, non-patient facing, or health professional shortage area special status must attest (submit a “yes”) to 1 activity.
All others must attest (submit a “yes”) to 2 activities.
All improvement activities are worth the same number of points.
Improvement activities have a continuous 90-day performance period (during CY 2021) unless otherwise stated in the activity description.
To find more information on improvement activities visit: https://qpp.cms.gov/mips/improvement-activities
Cost
In 2026, the Cost category makes up 30% of your final score. The performance period is 12 months.
There are 35 cost measures available for the 2026 performance period:
33 episode-based cost measures based on a range of procedures, acute inpatient medical conditions, chronic conditions, and care settings.
2 population-based cost measures focused more broadly on primary and inpatient care.
To learn more about reporting Cost measures, please refer to: https://qpp.cms.gov/mips/cost
FAQ
Q: My Patient Education numbers are low, but I provide patient education for my patients. Why is that?
A: Once the patient education has been provided, "Patient Education Provided" needs to be checked off under the MACRA tab in the Progress Note.
Q: I have created Clinical Decision Support Rules, but they did not save. Why is that?
A: In order for Clinical Decision Support Rule to be saved, Roles have to be defined. If you don’t define who can see the rule, it will not get saved.
