2025 DIY Guide to MSSP ACO eCQM Reporting: From Clinical Data Chaos to Submission Success

Is your Medicare Shared Savings Program (MSSP) ACO ready to tackle the complex world of electronic Clinical Quality Measures (eCQM) reporting? While some organizations consider building their own internal reporting capabilities, the reality is that aggregating data from multiple EHRs, ensuring measure compliance, and preparing submission-ready files requires significant expertise and coordination that many underestimate. 

eCQM reporting for MSSP ACOs isn’t just a technical checkbox, it’s a high-stakes, data-driven operation that directly impacts your quality scores and shared savings potential. This guide walks you through the essential steps: acquiring and validating data, identifying critical gaps, de-duplicating patients, monitoring quality performance, and generating compliant submission files. 

2025’s eCQM Landscape: What’s at Stake

For performance year 2025, MSSP ACOs must report four specific eCQM/MIPS CQM measures as part of the APP Plus quality measure set: 

1. Diabetes: Hemoglobin A1c (HbA1c) Poor Control
   The percentage of patients age 18–75 with diabetes whose most recent HbA1c is greater than 9.0%.
2.  Preventive Care and Screening: Depression Screening + Follow-Up Plan
   The percentage of patients age 12 or older who are screened for depression and, if positive, have a documented follow-up plan.
3. Controlling High Blood Pressure
   The percentage of patients age 18–85 with diagnosed hypertension whose blood pressure is controlled (meaning less than 140/90 mmHg).
4. Breast Cancer Screening
   The percentage of women age 50–74 who received a mammogram every one to two years. 

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