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MIPS Question and Answer Town Hall Event for Solo or Small Group
Practices
January QPP SURS LAN Webinar Questions and Answers
January 23 and 28, 2020
Resources:
For free MIPS Technical Assistance, contact: o FL, GA, NC, SC: Alliant GMCF
Phone: 844-777-8665 Email: [email protected] Submit request: https://www.surveymonkey.com/r/QPPHelpForm Website: http://www.alliantquality.org/
o AR, MO, OK, TX, PR, LA, MS, CO, KS: TMF Health Quality Institute Phone: 844-317-7609 Email: [email protected] Submit request: https://tmf.org/QPP/Request-Help Live chat: https://chat.tmf.org:8443/ECCChat/chat.html To join TMF’s Learning and Action Network: https://www.tmfqin.org/qpp
o AL, TN: QSource
Phone: 844-205-5540
Email: [email protected]
o NJ, PA, DE, WV: Quality Insights
Phone: 877-497-5065
Email: [email protected]
Website: https://www.qualityinsights.org
o NY, MD, DC, VA: IPRO
Phone: 866-333-4702
Email: [email protected] (change state code depending on the
state you practice in)
Submit request: https://ipro.org/for-providers/medicare-qpp/req-tech-assist
o WA, ID: Comagine Health
Phone: 877-560-2618
Email: [email protected]
Website: http://medicare.qualishealth.org/projects/QPP-resource-center
o MT, WY, UR, NV, OE, AK: Network for Regional Healthcare Improvement (NRHI)
For UT, OR, NV: Email: [email protected]
For MT, WY, AK: Email: [email protected]
o ND, SD, NE, IA: Telligen
Phone: 844-358-4021
Email: [email protected]
Submit request: https://telligenqpp.com/contact/
o MN, WI, MI, IL, IN, OH, KY: Altarum
Email: [email protected]
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o ME, NH, MA, VT, RI, CT: Healthcentric Advisors
Email: [email protected]
o NM, AZ, CA, HI: Health Services Advisory Group (HSAG)
Phone: 844-472-4227
Email: [email protected]
General QPP Information:
o QPP CMS Website: https://qpp.cms.gov/
o QPP CMS Resource Library: https://qpp.cms.gov/about/resource-library
o Locate your QPP SURS Technical Assistance Contractor:
https://qpp.cms.gov/about/small-underserved-rural-practices
o QPP Participation Status Tool: https://qpp.cms.gov/participation-lookup
o Technical Assistance Resource Guide: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/25/TA%20Resource%20Guide%202017%2004%20
24_Remediated.pdf
o Explore Measures Tool: https://qpp.cms.gov/mips/explore-measures/quality-measures
o QPP Access User Guide: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/335/QPP+Access+User+Guide.zip
o 2020 Quality Payment Program Final Rule:
https://www.federalregister.gov/documents/2019/11/15/2019-24086/medicare-
program-cy-2020-revisions-to-payment-policies-under-the-physician-fee-schedule-and-
other
o LAN Webinar Recordings, Transcripts, Q&As, and Slides: https://qppsurs.com/webinar-
resources/
o Certified Health IT Product List (CHPL): https://chpl.healthit.gov/#/search
o QPP Portal: https://qpp.cms.gov/login
2020 Performance Year:
o 2020 Quality Payment Program Final Rule:
https://www.federalregister.gov/documents/2019/11/15/2019-24086/medicare-
program-cy-2020-revisions-to-payment-policies-under-the-physician-fee-schedule-and-
other
o 2020 QPP Final Rule Overview Fact Sheet: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/737/2020%20QPP%20Final%20Rule%20Fact%20S
heet.pdf
o 2020 Shared Savings Program and QPP Interactions Guide: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/815/2020%20SPP%20and%20QPP%20Interactions
%20Guide.pdf
o 2020 Medicare Part B Claims Measure Specifications and Supporting Documents:
https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/787/2020+Medicare+Part+B+Claims+Measure+Sp
ecs+and+Supporting+Docs.zip
o 2020 Promoting Interoperability Measure Specifications: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/807/2020%20PI%20Measures.zip
o 2020 Clinical Quality Measure Specifications and Supporting Documents: https://qpp-
cm-prod-
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content.s3.amazonaws.com/uploads/786/2020+CQM+Specifications+and+Supporting+
Docs.zip
o 2020 Quality Benchmarks: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/824/2020%20MIPS%20Quality%20Benchmarks.zip
o 2020 Quality Performance Category Quick Start Guide: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/823/2020%20Quality%20Quick%20Start%20Guide
2019 Performance Year:
o TMF’s Finding Quality Measures Using Single Source Documents:
https://www.tmfnetworks.org/Portals/0/Resource%20Center/QA_Finding%20Quality%
20Measures%20Using%20Single%20Source%20Documents_508.pdf
o 2019 Improvement Activities Fact Sheet: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/453/2019%20Improvement%20Activities%20Fact
%20Sheet_Final.pdf
o 2019 Qualified Clinical Data Registries (QCDRs) Qualified Posting: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/347/2019%20QCDR%20Qualified%20Posting_Final
_v8.xlsx
o 2019 Qualified Registries Qualified Posting: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/348/2019%20Qualified%20Registry%20Posting_Fi
nal_v6.xlsx
o 2019 Clinical Quality Measure Specifications and Supporting Documents: https://qpp-
cm-prod-
content.s3.amazonaws.com/uploads/339/2019+CQM+Specifications+and+Supporting+
Docs.zip
o 2019 Promoting Interoperability Measure Specifications: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/343/2019%20Promoting%20Interoperability%20M
easure%20Specifications.zip
o 2019 Facility-based Measurement Fact Sheet: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/454/2019%20MIPS%20Facility-
Based%20Measurement%20Fact%20Sheet.pdf
o 2019 MIPS Quality Performance Category Fact Sheet: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/350/2019%20MIPS%20Quality%20Performance%2
0Category%20Factsheet.pdf
o 2019 Data Submission User Guide: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/901/2019%20QPP%20Data%20Submission%20Use
r%20Guide.pdf
o Manual Attestation of Promoting Interoperability Measures video:
https://youtu.be/UUfmDiXUByc
o Manual Attestation of Improvement Activities Measures video:
https://www.youtube.com/watch?v=8vjPeLxe9dA&feature=youtu.be
o 2019 Medicare Part B Claims Measure Specifications and Supporting Documents:
https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/338/2019+Medicare+Part+B+Claims+Measure+Sp
ecs+and+Supporting+Docs%C2%A0.zip
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o 2019 Claims Data Submission Fact Sheet: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/444/2019%20Claims%20Data%20Submission%20F
act%20Sheet.pdf
o Scores for Improvement Activities in MIPS APMs in the 2019 Performance Period:
https://protect2.fireeye.com/url?k=3bcca562-67988c49-3bcc945d-0cc47a6d17cc-
2fee5791bb55d9f4&u=https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/0/2019%20MIPS%20APMs%20IA%20Fact%20Shee
t.pdf
o 2019 MIPS APMs/APM Scoring Standard Overview presentation: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/528/2019%20MIPS%20APMs_APM%20Scoring%2
0Standard%20Overview_Slides.pdf
o 2019 QP Methodology Resources: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/735/2019%20QP%20Methodology%20Resources.z
ip
o 2019 Quality Benchmarks: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/342/2019%20MIPS%20Quality%20Benchmarks.zip
o 2019 MIPS Scoring Guide: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/599/2019%20MIPS%20Scoring%20Guide.pdf
2018 Performance Year:
o 2018 Performance FAQs: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/581/2018%20Performance%20Feedback%20FAQs.
Other Resources:
o Hierarchical Condition Categories Coding:
https://tmfnetworks.org/link?u=97bd3e
https://www.aafp.org/practice-management/payment/coding/hcc.html
o Annual Wellness Visits: https://qioprogram.org/annual-wellness-visit-bite-sized-learning
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Questions and Answers January 23 & 28, 2020
Eligibility and Reporting: 1. I work with several practices who use different EMRs. Is there a place for me to find out which
EMR is certified to report on which quality metrics? All EHRs must meet the 2015 Certified Electronic Health Record Technology (CEHRT) requirements to be eligible for the Promoting Interoperability Category. To find out which EHR systems meet the CEHRT requirements, see the Certified Health IT Product List (CHPL) on the ONC website. These requirements do not vary by quality measure, but some EHR vendors only offer a subset of the QPP electronic clinical quality measures. Please reach out to your EHR vendor to find out which quality measures can be captured by your EHR. In some cases, you may be able to negotiate with your EHR vendor to make additional QPP quality measures available to you. For a full list of QPP electronic clinical quality measures use the Explore Measures Tool.
2. I have one physician and four mid-levels, so would I only report as an individual rather than a group? The Quality Payment Program is not just for physicians. Other types of clinicians including physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, osteopathic practitioners, chiropractors, physical therapists, occupational therapists, clinical psychologists, qualified speech-language pathologists, qualified audiologists, and registered dietitians or nutrition professionals are also eligible to report to MIPS if they exceed the low-volume threshold. You should determine eligibility for each member of your practice by entering their NPI in the NPI Lookup Tool.
If your practice exceeds the low-volume threshold at the group level, you can report as a group. A group is defined as a set of clinicians – identified by their National Provider Identifier (NPI) – sharing a common Taxpayer Identification Number (TIN). An individual is defined as a single NPI tied to a single TIN. Each TIN/NPI combination is evaluated for MIPS eligibility. In order to be deemed MIPS eligible, clinicians must exceed the low-volume threshold in both 12-month determination periods. Clinicians are MIPS-eligible if they:
1. Bill more than $90,000 in Medicare Part B allowed charges for covered professional services payable under the Physician Fee Schedule (PFS); and
2. Provide covered professional services for more than 200 Part B-enrolled patients; and 3. Provide more than 200 covered professional services to Part B-enrolled patients.
3. So last year we were required to report. This year we are only opt-in eligible. If we choose not to opt-in, is there anything further we need to do to notify CMS that we choose not to opt in or submit at all? If we opt-in, are we subject to payment adjustments? If you are not required to report, and do not want to opt-in to the MIPS program, you do not need to take any additional action. Note that if you choose to opt-in or report any data, you will
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be subject to MIPS scoring and subsequent payment adjustments, and cannot later opt-out during this reporting year. During the data submission period (January 2, 2020 – March 31, 2020), clinicians, groups, and their third-party intermediaries can submit their election via the QPP Portal.
4. What happens if our 25 providers are located at different practices? They are under one TIN, but not at the same location. A group is defined as a set of clinicians – identified by their National Provider Identifier (NPI) – sharing a common Taxpayer Identification Number (TIN), no matter the specialty or practice location. You can check the NPI Lookup Tool to find out whether your providers are eligible for the MIPS program at the individual or group level.
5. If we had a provider leave halfway through the year, do we still report for them? CMS looks at each combination of individual NPI and Tax Identification Number (TIN) to make eligibility determinations. The MIPS determination period for 2019 consists of the two 12-month segments:
Segment #1: A 12-month segment beginning on October 1, 2017 and ending on September 30, 2018, plus a 30-day claims run out; and
Segment #2: A 12-month segment beginning on October 1, 2018 and ending on September 30, 2019. Segment #2 does not include a claims run out period.
When you sign into the QPP Portal, you will be able to see who CMS has determined as part of your practice. You can also use the NPI Lookup Tool to see which clinicians are associated with your practice. Please note if the clinicians were in your practice during the MIPS performance period, their data should be included when reporting as a group. If they left prior to the reporting period, they do not need to be included in your submission and they will not count against your status as a small practice. We encourage you to reach out to your region’s Technical Assistance Contractor for additional support. You can locate your local Technical Assistance Contractor here.
6. Our practice base is 80% inpatient. Is it possible to piggy back the hospital MIPS reporting, if so, how would we do this? When the majority of your patients are inpatients at a hospital or living in a nursing home or other facility, reporting can be a challenge. There are a few options that may be available to you. One is facility-based reporting. In order to be considered facility-based, MIPS eligible clinicians must meet the following criteria:
Bill at least 75 percent of your covered professional services in a hospital setting;
Bill at least one service in an inpatient hospital or emergency room; and
Can be attributed to a facility with a Hospital Value-based Purchasing (VBP) score. CMS will identify groups and virtual groups as facility-based if 75 percent or more of the MIPS eligible clinicians in a group or virtual group are deemed facility-based. Groups and virtual
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groups will be attributed to the hospital at which the plurality of their clinicians are attributed as individuals. If a practice is identified as facility-based and is attributed to a facility with a Hospital Value-Based Purchasing (HVBP) Program score, the practice will not be required to submit data for the Quality performance category. Instead, the HVBP score will be used for the Quality and Cost performance categories as long as the practice submits group-level data for the Improvement Activities and/or Promoting Interoperability performance categories. However, the practice may be eligible for reweighting for the Promoting Interoperability category. For more information on facility-based measurement, please see the 2019 Facility-based Measurement Fact Sheet. Alternatively, if your hospital is part of an Accountable Care Organization (ACO), you may consider joining. If you do, you will be able to report as part of the ACO in future reporting years. You can learn more about ACOs and other Alternative Payment Models here. For assistance with understanding facility-based measurement, please reach out to your region’s Technical Assistance Contractor. You can locate your local Technical Assistance Contractor here.
7. If we are determined to be exempt for the 2019 year, but still choose to report for MIPS as a small practice, does this mean that from here-on even if we receive exempt status in the future again, we will be required to report for the MIPS regardless of our status?
If you do not meet the MIPS eligibility criteria, you are not required to participate in MIPS, even if you have previously submitted MIPS data. MIPS eligibility is determined annually based on your clinician type, the date you enrolled in Medicare, participation in an Advanced Alternative Payment Model (AAPM), and the volume of care you provide to Medicare patients (referred to as the low-volume threshold). For more information on MIPS eligibility determination, please see the QPP website Eligibility Determination Period and Snapshots.
8. Is it better to report as a group or as individuals? Whether to report as a group or an individual is a decision you have to make based on your specific situation. To find out if you are eligible to report to the MIPS program as an individual or as a group, please enter your NPI in the NPI Lookup Tool. Your local Technical Assistance Contractor can assist you with making the decision to report as an individual or as a group. To locate your region’s Technical Assistance Contractor, click here.
9. How do other practices meet the incentive programs for Medicare Advantage plans? Many private insurers, including those who provide Medicare Advantage plans, have reporting programs similar to MIPS. If you are reporting under multiple programs, we encourage you to look for measures you can use across programs.
There are efforts underway to streamline reporting requirements across programs, so in the future reporting should become easier.
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In the meantime, you may be able to learn about other providers’ strategies through your professional association. If you already know which measures you will need to report on for Medicare Advantage, your Technical Assistance Contractor can help you look for corresponding MIPS measures. You can contact your region’s Technical Assistance Contractor for free personalized assistance. You can find the contact information for your local Technical Assistance Contractor here.
10. How do you know when your performance period begins if you have a provider that has never participated? If you are eligible for MIPS, then your performance period begins on January 1st and ends on December 31st of the calendar year. You can check your providers’ eligibility for the current reporting year using the QPP NPI Lookup Tool. Be sure to check back every couple of months since eligibility can change based on participation in an Advanced Alternative Payment Model (APM) or the two determination periods for eligibility. For more information on how MIPS eligibility is determined, please click here. For free, personalized assistance with reporting to the MIPS program, please contact your region’s Technical Assistance Contractor. You can find the contact information for your local Technical Assistance Contractor here.
11. Are reporting periods always one year? If you are eligible for MIPS in a given year, the performance period is the full calendar year. For the Quality performance category, you are expected to submit 12 months of data. For the Promoting Interoperability (PI) and Improvement Activity (IA) categories, you only have to submit data for 90 consecutive days. For further details about MIPS and reporting requirement, please review the 2019 MIPS Fact Sheet. We encourage you to contact your region’s Technical Assistance Contractor for free personalized assistance using contact information available here.
12. What should we be taking advantage of, as a small practice? There are a number of resources that are available to support your small practice. One of the most important resources is your regional Technical Assistance Contractor who is available to give you free, personalized support at every step of the reporting process. In addition to their ability to answer your questions and give advice, your Technical Assistance Contractor can provide you with resources, guides, and webinars. You can find your Technical Assistance Contractor’s contact information here. Another great resource for all practices is the QPP webpage, which includes all relevant information about measures, reporting deadlines, and program updates, as well as numerous guides and fact sheets. The website also has a page which describes support specifically for small, underserved, and rural practices. The QPP SURS Central Support Contractor also holds monthly webinars like this one which focus on a range of topics surrounding small practice reporting. You can find upcoming LAN webinars and recordings of past webinars here. As a small practice you may also be eligible for some reporting exceptions and bonuses, including the Promoting Interoperability hardship exception, reduced reporting requirements in the
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Improvement Activity Category, and small practice bonus in the Quality measures performance category. For additional flexibilities for small practices reporting to MIPS, please see the answer to question #94.
13. How do most practices submit their data? Is it mainly through registries, claim billing, or EMRs? In Performance Year 2017, the most common submission method was to submit data through a registry. However, practices have been successful using all forms of data submission. To learn more about submission types, check the resources available in the CMS QPP Resource Library. To learn how to submit data to the Quality Payment Program for the 2019 Performance Period, see the 2019 QPP Data Submission User Guide.
Year 4 Changes: 14. Will there be any changes for small practices in Behavioral Health for 2020?
The 2020 Mental/Behavioral Quality Measures Specialty Set is unchanged from 2019. You can view it here. For the Promoting Interoperability category, starting in 2020, the Query of Prescription Drug Monitoring Program measure is now an optional measure and is available for bonus points, the Verify Opioid Treatment Agreement measure was removed, and group practices will be eligible for reweighting when more than 75% of the NPIs in the group meet the definition of a hospital-based individual MIPS eligible clinician. There are also a number of changes in the 2020 Performance Year generally, that affect all eligible clinicians including behavioral health specialists. For the Quality measures category, CMS added three quality measures, removed 42 measures, increased the data completeness requirements, and established alternative benchmarks for measures. For the Cost category, CMS added new episode-based measures, changed the name of the Medicare Spending Per Beneficiary (MSPB) to Medicare Spending Per Beneficiary Clinician (MSPB-C), and changed how Total Per Capita Costs (TPCC) is attributed. In 2020 measure attribution will be different for individuals and groups and will be defined in the applicable measure specifications. For the Improvement Activities category, CMS added two new activities, modified 7 existing activities, and removed 15 activities. It also changed to definition of rural area. Beginning in 2020, groups or virtual groups can only attest to an improvement activity if at least 50% of the clinicians perform the same activity during any continuous 90-day period within the same performance year.
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To learn more about changes, start by reviewing the 2020 Quality Payment Program Final Rule Executive Summary and the 2020 Quality Payment Program FAQs. You may also want to utilize the Explore Measures Tool which has been updated for the 2020 Performance Year.
15. What are the major differences between 2019 and 2020 MIPS reporting? There are a few changes to the MIPS program for the 2020 Performance Year, as outlined in the 2020 Quality Payment Program Final Rule. The performance threshold for 2020 is 45 points and the additional performance threshold for exceptional performance is 85 points. The performance category weights did not change in 2020: Quality is weighted at 45%, Cost is weighted at 15%, Promoting Interoperability is weighted at 25%, and Improvement Activities is weighted at 15%.
For the Quality performance category, CMS is:
Increasing the data completeness threshold to 70%;
Continuing to remove low-bar, standard of care, process measures as they further implement the Meaningful Measures framework;
Addressing benchmarking for certain measures to avoid potentially incentivizing inappropriate treatment;
Focusing on high-priority outcome measures; and
Adding new specialty sets (Speech Language Pathology, Audiology, Clinical Social Work, Chiropractic Medicine, Pulmonology, Nutrition/Dietician, and Endocrinology).
For the Cost performance category, CMS is:
Adding 10 new episode-based measures to continue expanding access to this performance category; and
Revising the existing Medicare Spending Per Beneficiary Clinician and Total Per Capita Cost measures.
For the Improvement Activities performance category, CMS is:
Reducing barriers to patient-center medical home designation by removing specific examples of entity names of accreditation organizations or comparable specialty practice programs;
Increasing the participation threshold for group reporting from a single clinician to 50% of the clinicians in the practice needing to perform the same improvement activity; finalizing our proposal with modification, such that instead of requiring that a group must perform the same activity for the same continuous 90 days in the performance period, they are requiring that a group must perform the same activity during any continuous 90-day period within the same performance year;
Updating the Improvement Activity Inventory and establishing factors for consideration for removal; and
Concluding the CMS Study on Factors Associated with Reporting Quality Measures. For the Promoting Interoperability performance category, CMS is:
Including the Query of Prescription Drug Monitoring Program (PDMP) measure as an optional measure (available for bonus points);
Removing the Verify Opioid Treatment Agreement measure;
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Reducing the threshold for a group to be considered hospital-based (instead of 100% of clinicians, more than 75% of the clinicians in a group must be a hospital-based individual MIPS eligible clinician in order for the group to be excluded from reporting the measures under the Promoting Interoperability performance category and to have this category reweighted to zero);
Beginning with PY 2019, requiring a “yes/no” response instead of a numerator and denominator for the optional Query of PDMP measure;
Beginning with PY 2019, redistributing the points for the Support Electronic Referral Loops by Sending Health Information measure to the Provide Patients Electronic Access to Their Health Information measure (if an exclusion is claimed).
These are just a few of the changes, for more information please review the 2020 Quality Payment Program Final Rule Overview Fact Sheet.
16. What are the 2020 Telemedicine changes? CMS continues to expand the list of codes for using telehealth. In the 2020 Quality Payment Program Final Rule, the agency added three new HCPCS G-codes for opioid use disorder (OUD):
HCPCS code G2086: Office-based treatment for OUD, including development of the treatment plan, care coordination, individual therapy and group therapy and counseling (at least 70 minutes in the first calendar month)
HCPCS code G2087: Office-based treatment for opioid use disorder, including care coordination, individual therapy and group therapy and counseling (at least 60 minutes in a subsequent calendar month)
HCPCS code G2088: Office-based treatment for opioid use disorder, including care coordination, individual therapy and group therapy and counseling (each additional 30 minutes beyond the first 120 minutes; list separately in addition to code for primary procedure)
CMS discusses these telehealth codes in conjunction with the newly proposed Medicare Part B benefit for OUD provided by opioid treatment programs (OTPs), as well as in the new proposed bundled payment for office-based OUD. For more information, please review the 2020 Quality Payment Program Final Rule.
17. For 2020, are Social Workers eligible to take part in MIPS? No, Clinical Social Workers are not eligible to take part in MIPS in 2020. However, CMS has finalized a Clinical Social Work measure set to help these clinicians prepare in the event that they are added to the definition of a MIPS eligible clinician through future rulemaking. The Clinical Social Work specialty measure set can be found using Explore Measures Tool on the QPP Website. The tool allows you to search for measures by keyword, measure type, specialty, or collection type, and contains links to detailed descriptions of each measure. Please be sure you select the 2020 performance year to filter the measures for the performance year.
Data Submission: 18. Can we still do attestations for 2019?
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Yes, it is not too late to attest for the 2019 Performance year. Attestations are available for two performance categories: Improvement Activities and Promoting Interoperability. The deadline to submit data through the QPP portal for the 2019 Performance year is March 31, 2020. Please note that the 2019 performance period ended on December 31, 2019. Therefore, Improvement Activities and Promoting Interoperability measures must have been met by December 31, 2019. For more information on how to attest to the Promoting Interoperability and Improvement Activity categories, please watch the Manual Attestation of Promoting Interoperability Measures and Manual Attestation of Improvement Activities Measures videos.
19. Where do I go to set up a HARP account? Please visit the QPP website to register for a HCQIS Access Roles and Profile (HARP) account. Once you complete your HARP registration, you will be able to sign in to the QPP Portal. For more information on accessing the QPP Portal, please see the QPP Access User Guide.
20. When can we start submitting for 2019? You can start submitting data for the 2019 Performance Period now. For data submitted through the QPP Portal, the data submission period opened January 2, 2020 and ends at 8:00 pm ET on March 31, 2020. You can submit data as often as you like during this period and you’ll get a preview of your score. Starting your data submission early will give you time to identify any underperforming measures and fix data issues before the deadline. In addition, if you are submitting data via claims, the claims must be processed by your Medicare Administrative Contractor (MAC) within 60 days after the close of the performance period, so check with your MAC about their deadline for receiving your claims. Please contact your local Technical Assistance Contractor for help reporting for the MIPS program. Information for your region’s Technical Assistance Contractor can be found here.
21. Why is there no recourse after a certain point to correct a mistake? Once clinicians submit their data, CMS undergoes a process of analyzing it along with data from all other participating practices. If your practice encounters a specific error, you can reach out to your region’s Technical Assistance Contractor who can help you find an appropriate avenue to remedy the issue or work with you to develop strategies to avoid similar problems in future reporting years. You can find the contact information for your region’s Technical Assistance Contractor here.
22. Which is more accurate with submission, claims or registry? CMS expects all data to be accurate regardless of reporting method. If you submit data via claims, be sure to review the information you receive back from the Medicare Administrative Contractor (MAC) in the Remittance Advice (RA) or the Explanation of Benefits (EOB) to see if it
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the data submission was valid and successful. If you have concerns about the integrity of your data, we recommend that you reach out to your regional Technical Assistance Contractor for support. Please find your local Technical Assistance Contractor’s contact information here.
Claims-based Reporting: 23. Is this QDC thing you are talking about only if you are submitting directly from claims? It is not
from EHR, correct? Yes, quality data codes (QDCs) are only applicable if you report Quality performance category data via claims. The QDCs included on your claim forms identify which Medicare Part B claims Quality measures you are submitting. For more information coding for the Quality and Cost performance categories, please see TMF’s Q&A: Coding for Quality and Cost document.
24. What if when reporting by claims your provider does not have enough quality measures as an individual but they do as a group? For instance, we have physical therapists that do not have nine quality measures when we file by claims. Will this affect their score? Please note that beginning in the 2019 Performance Year, Medicare Part B claims measures can only be submitted by clinicians in a small practice (15 or fewer clinicians), whether participating individually or as a group. If your providers are part of a small practice and are eligible at a group level, then you may submit data for the MIPS program as a group and you will get an average score across all the clinicians in your group for each performance measure on which you are reporting. For the measures your practice has selected, if your physical therapists’ encounters were not denominator-eligible, or qualified for a denominator exclusion, and you applied the right codes, then your practice’s group score on those measures should not be affected. Check your measure specifications to make sure you are adding the right codes. You can download measure specifications for 2019 and 2020 at the links shown below: 2019 Medicare Part B Claims Measure Specifications and Supporting Documents 2020 Medicare Part B Claims Measure Specifications and Supporting Documents Note that for the Quality performance category you are only required to submit six measures, including at least one outcome measure or high-priority measure, and you can submit any combination of measures across data collection types to fulfill the 6-measure requirement. If you submit more than six measures, CMS will calculate your score based on the quality measures for which you earned the highest score. If you are reporting as a group, you should submit data for all eligible providers in your group and your physical therapists can also report individually. Their final score will be whichever score is highest: the group score or their individual score. For individual reporting they can:
Report on any six quality measures including at least one outcome measure or high-priority measure; OR
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Report on any six quality measures from their specialty set. If there are fewer than six measures in their specialty set, they are not required to report six quality measures, but they must report on all the measures in their specialty set.
In 2019 there were only four Medicare part B claims measures for physical/occupational therapists:
128: Preventive Care and Screening – Body Mass Index (BMI) Screening and Follow-Up Plan
130: Documentation of Current Medications in the Medical Record
131: Pain Assessment and Follow-Up
182: Functional Outcome Assessment
In 2020 there are eight Medicare part B claims measures for physical/occupational therapists. Measure 131 (Pain Assessment and Follow-Up) is no longer part of the set, and the following measures have been added:
134: Screening for Depression and Follow-Up Plan
154: Falls Risk Assessment
155: Falls: Plan of Care
181: Elder Maltreatment Screen and Follow-Up Plan
226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
You can search for 2019 and 2020 measures, and filter by specialty and mode of submission, here. Please check the NPI Lookup Tool to find out whether your providers are eligible to submit data as part of your group. If your providers submit less than the required 6 measures or no outcome or high priority measure, CMS will use the Eligibility Measure Applicability (EMA) process to see if they could have submitted more clinically related measures within the same collection type. If CMS finds that there are no applicable measures for your providers, they won’t be held accountable for not submitting all six measures and the denominator will be adjusted so that your score is based on the measures you did submit. If CMS finds additional clinically r-related measures could have been submitted and weren’t then your providers’ maximum number of points available for the Quality performance category won’t be reduced, resulting in a lower score for Quality. Please see the 2019 MIPS Quality Performance Category Fact Sheet for more information on reporting for the Quality performance category.
25. Am I able to report claims as an individual only for a large group? Beginning in the 2019 Performance Year, Medicare Part B claims measures can only be submitted by clinicians in a small practice (15 or fewer clinicians), whether participating individually or as a group. For more information on claims submission, please see the 2019 Claims Data Submission Fact Sheet.
26. When a claims-based measure does not specify a diagnosis, what ICD-10 code should be used for claim submission?
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You can use the Claims Single Source spreadsheet to search claims-based measures by diagnosis code (ICD-10-CM) and/or procedure/service code (CPT/HCPCS) and filter by the patient’s demographic. The Quality measure specifications can also be referenced to understand the full combination of codes that will make a patient denominator eligible. The 2019 Medicare Part B Claims Measure Specifications and Supporting Documents contain detailed instructions describing which codes to report for the numerator and denominator for each claims-based measure. The Claims Single Source spreadsheet is included in the supporting documents linked above.
27. How do you know if billing is submitting claims with HCC coding? HCC Coding involves thorough, specific ICD-10 diagnosis coding by your providers. HCC Coding training for providers and billing staff is essential. Be sure to review the information you receive back from the Medicare Administrative Contractor (MAC) in the Remittance Advice (RA) or the Explanation of Benefits (EOB) to see if it the data submission was valid and successful. Please reach out to your region’s Technical Assistance Contractor for free, personalized MIPS support. Information for your Technical Assistance Contractor can be found at https://qpp.cms.gov/about/small-underserved-rural-practices.
28. We still have paper charts, what is the best way to succeed in MIPS? What is the best way to track eligible populations in a small practice that uses paper charts? It is possible to be successful in the MIPS program without an EHR. For the Quality performance category, you can submit data via claims or a registry. For the Improvement Activities category you can submit an attestation via the QPP Portal. You cannot submit data for the Promoting Interoperability category using paper charts. If you do not have an EHR, you will need to obtain a Promoting Interoperability (PI) Hardship Exception to avoid receiving a 0 in this category. Clinician or groups may submit a PI Hardship Exception Application, citing one of the following reasons for review and approval:
MIPS eligible clinician in a small practice
MIPS eligible clinician using decertified EHR technology
Insufficient Internet connectivity
Extreme and uncontrollable circumstances
Lack of control over the availability of CEHRT
Please note that the PI Hardship Exception Application for Performance Year 2019 closed on December 31, 2019. The application for 2020 is not yet open. During the webinar, a Technical Assistance Contractor gave tips for being successful in MIPS using paper charts, including:
Make sure you know your office codes that relate to which Quality measures you plan to report
Identify your CPT codes that correspond to patient encounters during the performance period and identify which patients will be included in your denominator
Some claims-based practices will tag charts using color coding
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For more information on claims-based Quality reporting, please see the 2019 Claims Data Submission Fact Sheet. Learn more about exceptions you may be eligible for here. For assistance reporting to the MIPS program, please reach out to your local Technical Assistance Contractor. You can locate their contact information here.
29. We reported quality measures for 2019 using claim-based reporting, and when we log into our account through QPP, only 2 measures are being counted out of 7. Why is this happening? Are they still calculating all of the data? There may be several reasons for this. When you navigate to the Reporting Overview section of the QPP Portal, you should see the data and preliminary performance category scores for the data you submitted. CMS will update this feedback at the end of the submission period with claims processed by your Medicare Administrative Contractor (MAC) within the 60 day run out period. Please note that some special scoring considerations will be reflected in the QPP Portal as the information becomes available during the submission period. If submitting via claims, once you’ve submitted the claim form and included the QDC and other information to report your quality data via claims, you’ll need to review the information you receive back from the MAC in the Remittance Advice or the Explanation of Benefits to see if the data submission was valid and successful. The RA/EOB lists denial codes that correspond to the information you submitted on the claim form. When N620 is listed as a denial code, it tells you that the QDC(s) are valid for the 2019 MIPS performance period. If your MAC denies payment for all the billable services on your claim, the QDCs won’t be included in the MIPS analysis, and the corresponding claim’s data won’t count towards your Quality category submission. If you correct a denied claim and it gets paid through an adjustment, re-opening, or the appeals process by the MAC with accurate codes that go with the measure’s denominator, then any of the QDCs that apply and go with the numerator should also be included on the corrected claim. CMS will provide you with final performance feedback in July 2020 based on the data you submitted for the 2019 Performance Year. To receive help understanding why only two of your Quality measures are being counted, please contact your region’s Technical Assistance Contractor here. For more information on claims-based Quality reporting, please review the 2019 Claims Data Submission Factsheet.
30. What are your recommendations for providers with no EHR? Clinicians can participate in MIPS even if they do not have an electronic health record (EHR). If you are part of a small practice (15 or fewer eligible clinicians), we strongly encourage you contact your region’s Technical Assistance Contractor for free personalized assistance, including how you can report to MIPS without an EHR. You can find the contact information for your local Technical Assistance Contractor here. There are MIPS quality reporting options for eligible clinicians who do not have an EHR. For instance, eligible clinicians can report quality measures via claims or submit data through a registry that accepts non-EHR data submissions. You can read more about the claims data submission process in the Claims Data Submission Fact Sheet and review the MIPS published lists of Qualified Registries and Qualified Clinical Data Registries. You also do not need an EHR to submit data for the Improvement Activities category.
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Without an EHR, you cannot submit data in the Promoting Interoperability (PI) category. If you are part of a small practice (15 or fewer eligible clinicians), you can claim a PI hardship exception. If your hardship exception is approved, you do not have to report on the PI category, and the 25% weighting of the PI performance category will be reallocated to the Quality performance category. Unfortunately, the hardship exception application period has ended for the 2019 performance period, but you can apply in 2020. For more information about hardship exceptions, please visit the QPP Exceptions webpage.
31. What are the pros and cons of claims-based reporting? Small practices (15 or fewer eligible clinicians) can report MIPS data via claims for the 2019 and 2020 reporting periods. Many small practices find claims-based reporting familiar and convenient, especially if they don’t have an electronic health record (EHR). A drawback of claims-based reporting is that you may be limited in the types of measures you can select from, especially for clinicians seeking specialty-specific measures. In addition, Medicare does not provide regular status reports on your reporting. You can, however, review the information you receive back from your Medicare Administrative Contractor (MAC) in the Remittance Advice or the Explanation of Benefits to see if it the data submission was valid and successful. You also cannot report to the Promoting Interoperability category via claims. However, if you do not have an EHR, you may want to consider submitting a Promoting Interoperability (PI) Hardship Exception Application. Clinician or groups may submit a PI Hardship Exception Application, citing one of the following reasons for review and approval:
MIPS eligible clinician in a small practice
MIPS eligible clinician using decertified EHR technology
Insufficient Internet connectivity
Extreme and uncontrollable circumstances
Lack of control over the availability of CEHRT
Please note that the PI Hardship Exception Application for Performance Year 2019 closed on December 31, 2019. You can read more about the claims-based data submission process in the Claims Data Submission Fact Sheet. For free, personalized assistance with reporting to the MIPS program via claims, please contact your region’s Technical Assistance Contractor using contact information available here.
Alternative Payment Models (APMs): 32. We are part of a MIPS APM. When we go in and attest, we are getting 7.5 points for the
Improvement Activities. We called the QPP Helpdesk and they said that MIPS APMs only get 50%. However, presentations from QPP say that we get full credit. Which is it? While policy stipulates that MIPS APMs get at least 50% credit, all APM Entities participating in the following list of MIPS APMs will receive a full score for the improvement activities performance category in performance period 2019, and therefore will not need to submit additional improvement activity information under MIPS:
Maryland Total Cost of Care Model (Maryland Primary Care Program)
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Oncology Care Model (all Tracks)
Next Generation Accountable Care Organization (ACO) Model
Comprehensive End-Stage Renal Disease (ESRD) Care Model (all Tracks)
Bundled Payments for Care Improvement Advanced
Independence at Home Demonstration
Comprehensive Primary Care Plus Model (all Tracks)
Vermont All-Payer ACO Model (Vermont Medicare ACO Initiative)
Medicare Shared Savings Program (all Tracks, including the Medicare ACO Track 1+ Model)
(Reference: 2019 Scores for Improvement Activities in MIPS APMs) However, this credit is not displayed to groups participating in the Entity. When you sign into QPP to attest to Promoting Interoperability data on behalf of your practice, you’re seeing the 50% Improvement Activity credit that would be available if your practice were reporting as a group. This credit is available to and displayed for any practice with at least one clinician participating in an APM. Our system attributes APM participation to the individual clinician and not to the practice as a whole, since most MIPS APMs are not “full TIN” models. Performance feedback for clinicians scored under the APM scoring standard will be available in July to users with access to the APM Entity organization or to individual clinicians participating in the MIPS APM who have the “clinician role”. Only these users will see the full credit for the Improvement Activities performance category or any other information related to the APM scoring standard.
33. We are part of an ACO (with South Coast). Would you go over differences when part of an ACO? If you participate in a Medicare Shared Savings Program (Shared Savings Program) Accountable Care Organization (ACO), you may be part of a MIPS Alternative Payment Model (APM) or Advanced APM, depending on your ACO’s participation track within the Shared Savings Program. The 2020 Shared Savings Program and QPP Interactions Guide identifies the MIPS APM and Advanced APM status by Shared Savings Program ACO participation track and describes the MIPS APM scoring standard for eligible clinicians participating in an ACO. The guide also details the reporting requirements and who, the ACO or clinician, must report the data for each performance category.
Participating in a MIPS APM allows participants to receive special MIPS scoring under the APM scoring standard (unless you’re a Qualifying APM Participant), which is designed to reduce duplication of reporting and allow clinicians to focus on the goals of the APM. For more information about what it means to be in a MIPS APM, check out the MIPS APM Overview on the QPP website. For an overview of the APM Scoring Standard and reporting requirements, please review the 2019 MIPS APMS/APM Scoring Standard Overview presentation and transcript available in the CMS QPP Webinar Library.
34. How to attest if you are a QP in an APM?
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Sufficient participation in an Advanced APM allows you to achieve Qualifying APM Participant (QP) status and therefore receive a 5% APM incentive payment and be excluded from MIPS. To become a QP, you must receive at least 50 percent of your Medicare Part B payments or see at least 35 percent of Medicare patients through an Advanced APM entity at one of the determination periods (snapshots). In addition, 75 percent of practices need to be using certified EHR Technology within the Advanced APM entity. To become a Partial QP, you must receive at least 40 percent of your Medicare Part B payments or see at least 25 percent of Medicare patients through an Advanced APM entity at one of the determination periods (snapshots). All clinicians who participate in Advanced APMs and become Partial QPs may choose whether or not they want to participate in MIPS. If you are an eligible clinician currently participating in an Advanced APM, please contact your APM entity for participation specifics.
Please see the 2019 QP Methodology Resources for an overview of the determination of Qualifying Participants (QPs) and Partial QPs, how CMS will identify eligible clinicians participating in Advanced APMs, and how to calculate payment amount threshold scores in 2019.
35. What is the APM scoring standard for 2020? The APM Scoring Standard accounts for activities already required by the APM to reduce duplication of reporting and allow clinicians to focus on the goals of the APM. Therefore, the MIPS performance category weighting and reporting requirements are different than the general MIPS scoring standard. Eligible clinicians under an APM entity that is both an Advanced and MIPS APM that are not QPs or Partial Qualifying APM Participants (Partial QPs) are scored under the APM Scoring Standard. The performance category weights used to calculate the MIPS final score under the APM Scoring Standard for the 2020 performance period are as follows:
Quality: 50 percent
Improvement Activities: 20 percent
Promoting Interoperability: 30 percent
Cost: 0 percent
For more information on MIPS APMs and scoring, please visit the MIPS APM Overview on the QPP website.
36. Can you explain the quality reporting option for small practices in an APM? Certain Alternative Payment Models (APMs) include MIPS eligible clinicians as participants and hold their participants accountable for the cost and quality of care provided to Medicare beneficiaries. These types of APMs are called MIPS APMs, and participants receive special MIPS scoring under the APM Scoring Standard. The Quality score for MIPS APMs under the APM Scoring Standard is worth 50% of the total score. Different APMs may have different requirements for what quality data you must submit. Please reach out to your APM to find out what your specific requirements are. If you are in a Medicare Shared Savings Program (Shared
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Savings Program) ACO, you can review the 2020 Shared Savings Program and QPP Interactions guide for information on how the ACO will report quality data to CMS on behalf of participating clinicians. For additional information on MIPS APMs and to review the list of APMs, check out the MIPS APM Overview on the QPP website.
Registries: 37. I am reporting by registry for 2020. Do I need to sign up to report as a group for the 2020
deadline? MIPS-eligible clinicians can work with a Qualified Registry (QR) or a Qualified Clinical Data Registry (QCDR), to submit data for MIPS. A QR is an entity that collects clinical data from an individual MIPS-eligible clinician, group, or virtual group and submits it to CMS on their behalf. Clinicians work directly with their registry to submit data on the selected measures or specialty set of measures. A QCDR is a CMS-approved entity that collects clinical data on behalf of clinicians for data submission. Unlike QRs, QCDRs are not limited to standard measures within the Quality Payment Program, and can offer additional measures relevant to their specialty, which count towards MIPS scores. However, both QRs and QCDRs are required to provide performance feedback to participants at least quarterly, which can be helpful in monitoring your progress throughout the performance year. For a list of registries, please see the 2019 Qualified Registries Qualified Posting and the 2019 Qualified Clinical Data Registries (QCDRs) Qualified Posting. The 2019-Approved QCDR list includes measures noted as reportable via QCDR for vascular surgery.
CMS rules do not require you to report as a group just because you are reporting through a registry. If you do report as a group, you do not need to “sign up” or notify CMS that you will be reporting as a group. Instead, your registry can simply submit your data at the group level when the data submission period opens. Please work with your registry to understand their requirements and timelines for group submission, which may differ from CMS requirements and timelines.
38. How are benchmarks determined when using a registry? CMS establishes separate benchmarks for each data collection type. Qualified Clinical Data Registry (QCDR) measures, and Clinical Quality Measures (formerly known as Registry Measures) have their own benchmarks based on historical performance data. When a clinician or group submits measures for the MIPS Quality performance category, each measure is assessed against its benchmark for its collection type to determine how many points the measure earns. For the 2019 performance period, a clinician or group can receive 3 to 10 points for each measure that meets the data completeness standards and case minimum requirements by comparing measure performance to established Benchmarks. CMS establishes separate benchmarks for Qualified Clinical Data Registry (QCDR) measures since these measures do not have comparable specifications. For the 2019 and 2020 MIPS payment
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years, MIPS eligible clinicians and groups who report on QCDR measures that do not have an available benchmark but meet data completeness will receive 3 measure achievement points (small practices receive 3 points regardless of whether they meet the data completeness). For more information on measure benchmarks please see the 2019 Quality Benchmarks and the 2020 Quality Benchmarks.
39. If you are using a registry to enter your data, do you still need to apply for the hardship application for the registry?
You are exempt from reporting Promoting Interoperability (PI) if you're identified on the QPP Participation Status Tool as one of the following: 1) Ambulatory Surgical Center (ASC), 2) Hospital-based, or; 3) Non-patient facing. Additionally, the following clinician types also are exempt from reporting PI:
Physician assistants
Nurse practitioners
Clinical nurse specialists
Certified registered nurse anesthetists
Physical therapists
Occupational therapists
Qualified speech-language pathologists
Qualified audiologists
Clinical psychologists
Registered dietitian or nutrition professionals If you are exempt from submitting Promoting Interoperability, you do not need to apply for the PI hardship exception. However, if you are not exempt given the criteria above, MIPS eligible clinicians, groups, and virtual groups may submit a Promoting Interoperability Hardship Exception Application citing one of the following specified reasons:
You're a small practice
You have decertified EHR technology
You have insufficient Internet connectivity
You face extreme and uncontrollable circumstances such as disaster, practice closure, severe financial distress or vendor issues
You lack control over the availability of CEHRT Please note that the PI Hardship Exception Application for Performance Year 2019 closed on December 31, 2019. If you receive an exception for the PI category, the PI category would receive a 0 weight in calculating your final score, and the 25% is reallocated to the Quality category, making the Quality category worth 70 points. If you receive the exception, make sure you do not submit PI data and contact your registry so they do not inadvertently submit data on your behalf. Also, retain all verification of the request to your vendor. Visit the QPP website for more information on QPP exceptions.
40. Anyone else having problems with the IRIS registry dashboard?
For any issues with your registry, we recommend contacting your vendor. You may also want to consult other clinicians in your professional association to find out if they are facing similar
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challenges. For additional support, please reach out to your region’s local Technical Assistance Contractor. You can locate your local Technical Assistance Contractor here.
41. What are common clinical data registries in the area? MIPS eligible clinicians, groups, or virtual groups can work with a third-party intermediary, like a Qualified Registry (QR) or a Qualified Clinical Data Registry (QCDR), to submit data for MIPS. A QR is an entity that collects clinical data from an individual MIPS-eligible clinician, group, or virtual group and submits it to CMS on their behalf. Clinicians work directly with their registry to submit data on the selected measures or specialty set of measures. A QCDR is a CMS-approved entity that collects clinical data on behalf of clinicians for data submission. Unlike QRs, QCDRs are not limited to standard measures within the Quality Payment Program, and can offer additional measures relevant to their specialty, which count towards MIPS scores. However, both QRs and QCDRs are required to provide performance feedback to participants at least quarterly, which can be helpful in monitoring your progress throughout the performance year. For a list of registries, please see the 2019 Qualified Registries Qualified Posting and the 2019 Qualified Clinical Data Registries (QCDRs) Qualified Posting. The 2019-Approved QCDR list includes measures noted as reportable via QCDR for vascular surgery. For more information about the specific registries in your region, please contact your local Technical Assistance Contractor Information for your region’s Technical Assistance Contractor can be found at https://qpp.cms.gov/about/small-underserved-rural-practices?py=2020.
Quality Measures: 42. What items do you suggest Gastroenterologists to include in their MIPS?
You can find Gastroenterology measures for Performance Year 2019 by filtering the Explore Measures Tool on the QPP website by Gastroenterology Specialty Measure set. You can also find the 2020 measure set using the same tool. You can read more about specialty by visiting the 2019 Clinical Quality Measure Specifications and Supporting Documents. Some Gastroenterology measures include: 439: Age Appropriate Screening Colonoscopy; 390: Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options; and 275: Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy. Your local Technical Assistance Contractor can also help you identify measures that best suit your practice. Information for your region’s Technical Assistance Contractor can be found here. Information on how to find quality measures using single source documents can be found here.
43. For measure 440, we report through Healthmonix. Our office is Dermatology, so they send the specimen out and receive it back from the lab confirmed and communicated. Is 88305-26 billed correct to report? Healthmonix is a Qualified Registry, and Quality ID #440 is Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma (SCC): Biopsy Reporting Time – Pathologists to Clinician. This measure captures the percentage of biopsies with a diagnosis of cutaneous BCC and SCC in which the pathologist
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communicates results to the clinician within 7 days from the time when they tissue specimen was received by the pathologist. The denominator for this measure includes patient procedures during the performance period which were billed under CPT codes 88304 or 88305 during the reporting period. G9785 is the numerator code that shows the performance standard was met, and G9786 is the numerator code to use when the performance standards was not met. See the MIPS Clinical Quality Measure specifications for Quality ID #440 for more details.
44. What items need to be included for MIPS for pain management? You can find measures related to pain management using the Explore Measures Tool on the QPP website. Some Quality measures related to pain management include: 131: Pain Assessment and Follow-Up; 143: Oncology: Medical and Radiation – Pain Intensity Quantified; and 473: Average Change in Leg Pain Following Lumbar Fusion Surgery. Your local Technical Assistance Contractor can also help you identify measures that best suit your practice. Information for your region’s Technical Assistance Contractor can be found here. TMF has a resource that explains how you can find quality measures using single source documents. This resource is available here.
45. What is the distinction between an eCQMs and MIPS CQMs? Our EHR has us upload our files to a registry, which sends them to CMS. Is this ECQM or MIPS CQM? Electronic Clinical Quality Measures (eCQMs) are Quality measures reported automatically through Electronic Health Records (EHRs). They require structured data fields to capture data electronically. MIPS Clinical Quality measures (CQMs) (formerly known as Registry Measures) are measures reported through registries, either based on a file from your EHR or based on manual data abstraction. Please reach out to your EHR vendor to find out if the measures you are reporting through your EHR and registry are eCQMs or MIPS CQMs.
46. We are a small Radiology group from Michigan. There are not a lot of Radiology options and a lot of them are topping out. Will there be more options in 2020? You can filter the Explore Measures Tool but specialty to view the 2020 Diagnostic Radiology Specialty Measure Set or the Interventional Radiology Specialty Measure Set. You can also sort and search measures by specialty and view which measures are topped out by downloading the 2020 Quality Benchmarks. Some radiology measures include: 405: Appropriate Follow-up Imaging for Incidental Abdominal lesions, 436: Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques, and 145: Radiology: Exposure Dose Indices or Exposure Time and Number of Images Reported for Procedures Using Fluoroscopy.
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Additional measures may be available through Qualified Clinical Data Registries (QCDRs). A QCDR is a CMS-approved entity that collects clinical data on behalf of clinicians for data submission. QCDRs are not limited to standard measures within the Quality Payment Program, and can offer additional measures relevant to their specialty, which count towards MIPS scores. For example, the American College of Radiology’s QCDR offers 14 additional measures in 2020. Your local Technical Assistance Contractor can also help you with identifying measures that best suit your practice. Information for your region’s Technical Assistance Contractor can be found here. In addition, TMF has a resource that explains how you can find quality measures using single source documents. You can view this resource here.
47. I read somewhere that there were a couple of new measures for Chiropractic, but I was unable to find them. Beginning with the 2020 Performance Year, CMS added a Chiropractic Medicine specialty set for the Quality performance category. You can find Chiropractic Medicine measures on the QPP website. You can also use the Explore Measures Tool and filter by the Chiropractic Medicine specialty measure set. You can also sort and search measures by specialty by visiting the 2020 Clinical Quality Measure Specifications and Supporting Documents. Some Chiropractic Medicine measures include: 386: Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences, 472: Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture, and 459: Back Pain After Lumbar Discectomy/Laminectomy.
48. Our EHR is an Oncology specific EHR. However, they are very limited on what quality measures they support/report on. Most of the measures were designed for PCPs. How can we report on other measures that are actually “meaningful” to our specialty? You can find Oncology/Hematology measures by clicking https://qpp.cms.gov/mips/explore-measures/quality-measures?specialtyMeasureSet=Oncology%2FHematology. You can also use the Explore Measures Tool on the QPP website and filter by Oncology/Hematology specialty measure set and by performance year. You can also sort and search measures by specialty by visiting the 2019 Clinical Quality Measure Specifications and Supporting Documents and 2020 Clinical Quality Measure Specifications and Supporting Documents. Some Oncology/Hematology measures include: 462: Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy, 449: HER2 Negative or Undocumented Breast Cancer for Patients Spared Treatment with HER2-Targeted Therapies, and 143: Oncology: Medical and Radiation – Pain Intensity Quantified. In addition, MIPS-eligible clinicians can work with a Qualified Registry (QR) or a Qualified Clinical Data Registry (QCDR), to submit data for MIPS. For more information on QRs and QCDRs, please see the answer to question #37.
49. Where do I find the category II code or HCPCS code that quality measures translate to?
The Healthcare Common Procedure Coding System (HCPCS) codes can be found in the measure specification for each Quality measure. Please review the 2020 Medicare Part B Claims Measure
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Specifications and Supporting Documents to find the HCPCS codes for the Quality measures you plan to report.
50. What are the requirements for Quality Improvement Measure 374? Quality measure 374 is Closing the Referral Loop: Receipt of Specialist Report. It measures the percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred. For a full description of the measure and its requirements please see the eCQI Resource Center. To learn more about this and other measures, visit the Explore Measures Tool on the QPP Website. The tool allows you to search for measures by keyword, measure type, specialty, or collection type, and contains links to detailed descriptions of each measure.
51. How can we overcome the difficulty of finding specialty measurements?
In the 2020 reporting year, there are 46 specialty measure sets that clinicians can choose to submit. In doing so, clinicians must submit data on at least 6 measures within that set. If the set contains fewer than 6 measures, the clinician or practice should submit each measure in the set. To explore the available specialty measure sets, use the Explore Measures Tool on the QPP Website and filter measures by specialty measure set. If none of the available sets are a good fit for your practice, we recommend consulting the state or national professional association for your specialty. Often these organizations will provide guidance on what measures are relevant. Finally, you can contact your region’s Technical Assistance Contractor for free personalized assistance, including help selecting measures. You can find the contact information for your region’s Technical Assistance Contractor here.
52. We need measures pertinent to bariatric surgery. While there are no quality measures or measure sets specific to bariatric surgery, you can search for measures that may be applicable to your practice using the Explore Measures Tool on the QPP website. Some measures you might consider include:
130) Documentation of Current Medications in the Medical Record
326) Advance Care Plan
354) Anastomotic Leak Intervention
404) Anesthesiology Smoking Abstinence
236) Controlling High Blood Pressure
355) Unplanned Reoperation within the 30 Day Postoperative Period If you are still struggling to find measures that are a good fit for your practice, we recommend consulting the state or national professional association for your specialty. Often these organizations can provide guidance on what measures are relevant.
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53. What items do you suggest Colon-Rectal Surgeons include in their MIPS? There are no measures or measure sets that are specific to colon rectal surgery. However, there are a number of more general measures that may be a good fit for your practice. Please see question #51 and question #52 for more guidance.
54. I am looking into measure 440, Skin Cancer Biopsy Reporting Time, wondering if that is appropriate for our Dermatologists to report. I need some clarification on how the measure requirements are applied. Quality ID: 440 Skin Cancer: Biopsy Reporting Time – Pathologist to Clinician measure captured the percentage of biopsies with a diagnosis of cutaneous Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC), or melanoma (including in situ disease) in which the pathologist communicates results to the clinician within 7 days from the time when the tissue specimen was received by the pathologist. For more information on how to report this measure, please refer to the measure specifications, which includes a detailed description of the measure and instructions on how to document the measure based on your MIPS submission type. This measure is included in the Dermatology specialty measure set, which can be viewed on the QPP website by clicking on the “Explore Measures and Activities” tool and filtering the specialty measure set by “Dermatology.”
55. When will the specialty specific Quality Measures be available and where can I find them? Specialty-specific quality measures are available on the QPP website under the Explore Measures Tool. On this website, you can filter the available Quality measure by your specialty measure set. Additionally, you can download all the Performance Year 2020 Quality Measures and specifications by downloading the 2020 Clinical Quality Measure Specifications and Supporting Documents or the 2020 Medicare Part B Claims Measure Specifications and Supporting Documents.
56. Is there a minimum number of patients required for a provider to report a measure? You can report on any measure if you have at least one patient who meets the criteria for inclusion. If you are in a small practice (15 or fewer eligible clinicians), you will receive 3 achievement points for a measure you report on, even if you do not meet volume requirements and data completeness requirements for the measure. To get full points on individual measures, you will need to meet volume requirements (typically at least 20 patients) and data completeness requirements. Volume requirements vary for each measure, so be sure to review measure specifications. Data completeness requirements vary by collection type. For instance, if reporting via Medicare Part B claims, the data completeness requirement for 2019 is 60 percent of individual MIPS eligible clinician’s or group’s Medicare Part B patients for the performance period. More information about data completeness requirements by collection type can be found in Appendix C of the 2019 MIPS Quality Performance Category Fact Sheet.
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57. What 2020 metrics are geriatric practices servicing nursing homes and assisted living facilities selecting? You can find Gastroenterology measures for Performance Year 2020 by clicking https://qpp.cms.gov/mips/explore-measures/quality-measures?py=2020&specialtyMeasureSet=Geriatrics or by using the Explore Measures Tool on the QPP website and filtering on the Geriatrics Specialty Measure set. You can also sort and search measures by specialty by visiting the 2019 Clinical Quality Measure Specifications and Supporting Documents. Some Geriatrics measures include: 283: Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management; 181: Elder Maltreatment Screen and Follow-up Plan; and 154: Falls: Risk Assessment. Your local Technical Assistance Contractor can also help you identify measures that best suit your practice. Information for your region’s Technical Assistance Contractor can be found at https://qpp.cms.gov/about/small-underserved-rural-practices. In addition, TMF has a resource that explains how you can find quality measures using single source documents. This resource is available at https://www.tmfqin.org/Portals/0/Resource%20Center/Quality%20Payment%20Program/QA_Finding%20Quality%20Measures%20Using%20Single%20Source%20Documents_508.pdf.
58. We need advice on selecting measures for providers who only see patients at nursing homes and assisted living facilities when the facility owns the patients’ records. There are a number of measures that may be appropriate for physicians who work with patients in nursing homes. A good place to start may be to check the Geriatrics specialty measure set which you can find in the Explore Measures Tool on the QPP website. You do not have to be a geriatrics specialist to report using this measure set. If you face challenges collecting data and the facilities you work with possess your patients’ records, your best course of action will be to collaborate with them to obtain the data you need.
59. Can measure 410 be linked to the provider who prescribes a medication and/or instead of to the billing provider?
You can read the detailed description of Quality ID #410: Psoriasis: Clinical Response to Systematic Medications here. This measure is to be submitted a minimum of once per performance period for all patients during the performance period. The most recent denominator eligible encounter should be used to determine if the numerator action was performed. This measure may be submitted by the MIPS eligible clinicians who perform the quality actions described in the measure based on services provided and the measure-specific denominator coding. For measure-specific guidance, we recommend contacting the Quality Payment Program Service Center at [email protected].
60. What are the retired quality measures and new added measures for 2020? There are three new Quality Measures available for reporting in 2020. These measures include:
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International Prostate Symptom Score (IPSS) or American Urological Association-Symptom Index (AUA-SI) Change 6 -12 Months After Diagnosis of Benign Prostatic Hyperplasia (eCQM) (Quality ID: 476)
Multimodal Pain Management (MIPS CQM) (Quality ID: 477)
Functional Status Change for Patients with Neck Impairments (MIPS CQM) (Quality ID: 478)
There were also 42 quality measures removed in 2020. For more information on active quality measures, see the 2020 MIPS Clinical Quality Measure Specifications and Supporting Documents, or the 2020 Medicare Part B Measures Specifications and Supporting Documents if you are reporting via claims. In addition, we encourage you use the Explore Measures Tool on the QPP Website to identify measures. The tool allows you to search for measures by keyword, measure type, specialty, or collection type, and contains links to detailed descriptions of each measure. Please be sure you select the 2020 from the dropdown menu to find measures available for the 2020 performance year.
Improvement Activities: 61. As a small practice, I can report two medium measures. Is it a problem if I report three
medium measures? One would be a backup. The purpose of the Quality Payment Program is to improve the quality of care for patients, so if you have done more than meet the minimum requirements in the Improvement Activity performance category, it’s not a problem – it’s an achievement. Practices with 15 or fewer clinicians are considered small practices. For the Improvement Activity performance category, small practices are required to attest to 1 high-weighted activity or two medium-weighted activities. Small practices get double points for improvement activities, so you get 40 points for each high-weighted activity you attest to, and 20 points for each medium-weighted activity you attest to. You may attest to more than the required activities, but you can’t earn more than 40 points in this performance category, regardless of the number of activities you submit. In addition, improvement activities can contribute toward no more than 15% of your MIPS final score.
62. Do you need 100% in a survey? No – and even professional survey research firms find it almost impossible to get a 100% response to any survey. With that said, a good response rate and representative sample will give you more useful information to improve the patient experience. Using a third-party vendor to administer a survey can help you to get a good response rate. Some of the survey measures require you to use a third-party vendor. If you administer your own survey, in the event of an audit, you may need to show that you made an effort to capture responses from a sample that is as close to representative as possible.
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Practices with 25 or more eligible clinicians, which submit data through the CMS Web Interface, have the option to administer the CAHPS for MIPS survey as a Quality Measure. In addition, all practices regardless of size can choose to report on Improvement Activities that involve surveys. Two of these activities are:
IA_BE_13: Regularly assess the patient experience of care through surveys, advisory councils, and/or other mechanisms (medium-weighted activity). These surveys should be administered independently to the best extent possible. Suggested documentation to have includes survey results, advisory council notes, and/or other methods showing regular assessments of the patient care experience to improve the experience, taking into account specific populations served and including them in the assessment, such as identified vulnerable populations.
IA_BE_6: Collection and follow-up on patient experience and satisfaction data on beneficiary engagement (high-weighted activity). This survey must be administered by a third party survey administrator/vendor. Suggested documentation to have includes documentation of collection and follow-up on patient experience and satisfaction and of a patient experience and satisfaction improvement plan.
Please note that each of the Improvement activities you attest to must be performed for at least 90 continuous days during 2019. For the 2019 Performance Year, if one MIPS eligible clinician in a group completes and attests to an improvement activity, the entire group will receive credit for that improvement activity. For the 2020 Performance Year, groups and virtual groups can only attest to an improvement activity if at least 50% of the clinicians perform the same activity during any continuous 90-day period within the same performance year.
63. We have an EMR and will submit data to QPP. How can I add additional quality improvement activities done in the office, but not captured in the EMR? Even if you are submitting data for the Quality performance category using certified electronic health record technology (CEHRT), if your Improvement Activities were not fully captured by your EMR you can manually attest on your Improvement Activities through the QPP Portal or a third part vendor (QCDR or QR) cam submit your Improvement Activity category data on your behalf.
64. After you attest to the improvement activities on the QPP website, are there any other steps necessary to complete the attestation process for MIPS 2019?
CMS published a video on the QPP Resource Library that provides an overview of how a third-party intermediary, such as a Qualified Registry, can report MIPS data on behalf of a group within the Quality Payment Program portal, as well as how to modify the Improvement Activity (IA) score by manually attesting to measures. For support with confirming if you have completed reporting requirements, we recommend contacting your region’s Technical Assistance Contractor. Your local Technical Assistance Contractor can help you attest to the Improvement Activity category. You can find the contact information for your Technical Assistance Contractor here.
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65. For Improvement Activities, how important is it to be PCMH/NCQA certified? Your practice does not need to be a recognized Patient Centered Medical Home (PCMH) to succeed in the Improvement Activities category. That being said, a MIPS eligible clinician who is in a practice that is certified or recognized as a PCMH or comparable specialty practice will receive 100 percent for the Improvement Activities performance category. For more information on the Improvement Activities category, please see the 2019 Improvement Activities Fact Sheet.
Promoting Interoperability: 66. Does a prescription have to be submitted with a query to receive the bonus points or is just
one query required? Query of the Prescription Drug Monitoring Program (PDMP) is a 2020 Promoting Interoperability Category Measure. To meet the measure, for at least one Schedule II opioid electronically prescribed using certified electronic health record technology (CEHRT) during the performance period, the MIPS eligible clinician must use data from CEHRT to conduct a query of a PDMP for prescription drug history, except where prohibited and in accordance with applicable law. To report this measure, the MIPS eligible clinician must attest YES to conducting a query of a PDMP for at least one Schedule II opioid electronically prescribed using CEHRT. Please note that this measure is not required for the Promoting Interoperability performance category, but can earn a MIPS eligible clinician 5 bonus points. Although eligible clinicians do not need to submit a prescription for this measure, please make sure you to have documentation available for everything you report to MIPS in the case of an audit. There’s a helpful resource to organize your files in case of an audit here. You can read more about the specifications of the measure here.
67. How do I find out how to do a qualified risk assessment? Is there a certain number of patients this must be performed on? Where is the free security risk analysis tool? Do we have to upload the security risk analysis online? The Security Risk Analysis (SRA) is a Promoting Interoperability category measure. To meet this measure, MIPS eligible clinicians must conduct or review a security risk analysis in accordance with the requirements in 45 CFR 164.308(a)(1), including addressing the security (to include encryption) of ePHI data created or maintained by certified electronic health record technology (CEHRT) in accordance with requirements in 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3), implement security updates as necessary, and correct identified security deficiencies as part of the MIPS eligible clinician’s risk management process. To meet this measure, MIPS eligible clinicians must attest YES to conducting or reviewing a security risk analysis and implementing security updates as necessary and correcting identified security deficiencies. Eligible clinicians are not required to upload the SRA but should maintain it in the case of an audit. The SRA tool can be found here.
68. We just got a new EMR system last year, but we did not know how to do a patient portal. Is it too late to do the patient portal for 2019?
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The patient portal is a method of meeting the Promoting Interoperability measure, Provide Patients Electronic Access to their Health Information. To meet this measure, for at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT). All Performing Interoperability measures must be met by the final day of the performance period. The final day of the 2019 performance period was December 31, 2019, so it is too late to earn credit for the Provide Patients Electronic access to their Health Information measures for 2019. However, this measure is still a required Promoting Interoperability measure in 2020, so it will benefit your practice to introduce a patient portal now. For more information on this measure and other Promoting Interoperability measures, please review the 2019 Promoting Interoperability Measure Specifications, and the 2020 Promoting Interoperability Measure Specifications.
69. We are on the first year of EMR. Is the patient portal necessary or is it MyChart? MyChart is a type of patient portal for Epic EHR systems, so it is one method of meeting the Provide Patients Electronic Access to their Health Information Promoting Interoperability measure, which is a required measure for the Promoting Interoperability performance category. If you have a different EHR, there are other ways to meet this requirement. Please see the answer to question #68 for more information on this measure. For more information on this measure and other Promoting Interoperability measures, please review the 2019 Promoting Interoperability Measure Specifications, and the 2020 Promoting Interoperability Measure Specifications.
70. Am I able to attest as true to ONC direct review attestation even though we did not have anyone participate in patient portal? But we also did not deny access to records. To earn a score for the Promoting Interoperability performance category, you must use 2015 edition CEHRT, submit a “yes” to the Prevention of Information Blocking Attestation, submit a “yes” to the ONC Direct Review Attestation, submit a “yes” for the Security Risk Analysis measure, and report the required measures under each objective (which include the Provide Patients Electronic Access to their Health Information Promoting Interoperability measure) or claim any applicable exclusions. See question #68 for an explanation of this measure. Patient portal measure specifications don’t require patients to use the patient portal. They only require you to provide at least one patient with all of the necessary information needed to view, download, or transmit their information within no more than 4 business days of the information being available to the MIPS-eligible clinician. This could include providing patients with instructions on how to access their health information, the website address they must visit for online access, a unique and registered username or password, instructions on how to create a
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login, or any other instructions, tools, or materials that patients need in order to view, download, or transmit their information. Attesting to the ONC Direct Review shows that the MIPS eligible clinician is aware of the requirement to cooperate in good faith with ONC Direct review of their health information technology if a request is received. You technically could submit a “yes” to the ONC Direct Review Attestation and a “no” on the Provide Patients Electronic Access to their Health Information measure, but you would get a zero score because Provide Patients Electronic Access to their Health Information is a required measure for the Promoting Interoperability performance category. Please see the 2019 Promoting Interoperability Measure Specifications for more information.
71. Is it too late to do the SRA for 2019? Yes, it is too late to conduct the Security Risk Analysis (SRA) for the 2019 Performance Year. The SRA must be conducted with the calendar year of the MIPS performance period (January 1st – December 31st). However, the SRA is still a required Promoting Interoperability measure in 2020. You can read about the 2020 SRA measure specifications here.
72. Can you shed some light on the opioid questions if our EHR doesn’t give us a report? There are two opioid Promoting Interoperability measures: Query of the Prescription Drug Monitoring Program (PDMP) and Verify Opioid Treatment Agreement. These measures are both optional and each is worth 5 bonus points. To meet the Query of PDMP measure, for at least one Schedule II opioid electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a Prescription Drug Monitoring Program (PDMP) for prescription drug history, except where prohibited and in accordance with applicable law. To meet the Verify Opioid Treatment Agreement measure, for at least one unique patient for whom a Schedule II opioid was electronically prescribed by the MIPS eligible clinician using CEHRT during the performance period, if the total duration of the patient's Schedule II opioid prescriptions is at least 30 cumulative days within a 6-month look-back period, the MIPS eligible clinician seeks to identify the existence of a signed opioid treatment agreement and incorporates it into the patient's electronic health record using CEHRT. We recommend you speak with your EHR vendor, to determine if there is a way to report these measures using your system. If not, you may pursue an alternative CEHRT or else forgo these measures which are optional. Additionally, you may want to consider submitting a Promoting Interoperability (PI) Hardship Exception Application. Please see the answer to question #82 for more information on the PI Hardship Exception. Please contact your local Technical Assistance Contractor for help reporting for the Promoting Interoperability category. Information for your region’s Technical Assistance Contractor can be found here.
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73. Where do we find the Promoting Interoperability Hardship Exception application? The Promoting Interoperability (PI) Hardship Exception application is no longer available for the 2019 Performance Year. The deadline to submit the Hardship Exception was December 31, 2019. The 2020 Performance Year PI Hardship Exception application will likely be available summer of 2020. You can find more information on QPP exceptions here.
74. For specialties such as Ophthalmology, is it expected that we will continue to claim an exclusion for one of the two required for the PI Registry measure? We participate and report through our specialty’s QCDR (IRIS) but I'm not sure what other registry we could use. The requirement for the Public Health Registry Reporting measure is that the MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries. A MIPS eligible clinician meeting may be excluded from the Public Health Reporting measure if the MIPS eligible clinician:
Does not diagnose or directly treat any disease or condition associated with a public health registry in the MIPS eligible clinician’s jurisdiction during the performance period; OR
Operates in a jurisdiction for which no public health agency is capable of accepting electronic registry transactions in the specific standards required to meet the CEHRT definition at the start of the performance period; OR
Operates in a jurisdiction where no public health registry for which the MIPS eligible clinician is eligible has declared readiness to receive electronic registry transactions as of 6 months prior to the start of the performance period.
Please review the 2019 Promoting Interoperability Measure Specifications for more measure details. To find more registry options, please review the 2019 Qualified Registries Qualified Posting and the 2019 Qualified Clinical Data Registries (QCDRs) Qualified Posting, which provide lists of the 2019 CMS-approved registries for the MIPS Program. We encourage you to reach out to your region’s Technical Assistance Contractor for additional support. You can locate your local Technical Assistance Contractor here.
75. I would like to know more about Promoting Interoperability and the Clinical Data Exchange.
The Promoting Interoperability performance category promotes patient engagement and electronic exchange of information using certified health record technology (CEHRT). The Public Health and Clinical Data Exchange objective supports the ongoing systematic collection, analysis, and interpretation of data that may be used in the prevention and controlling of disease through the estimation of health status and behavior. The integration of health IT systems into the national network of health data tracking and promoting improves the efficiency, timeliness, and effectiveness of public health surveillance. For the Public Health and Data Exchange objective you must attest “yes” to being in active engagement with two public health or clinical registries for any of the five measures associated with this objective. Those five measures are 1) Immunization Registry Reporting, 2) Electronic Case Reporting, 3) Public Health Registry Reporting, 4) Clinical Data Registry Reporting, and 5)
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Syndromic Surveillance Reporting. For more information on the Public Health and Clinical Data Exchange measures, please see the 2019 Promoting Interoperability Measure Specifications and the 2020 Promoting Interoperability Measure Specifications. Please reach out to your region’s Technical Assistance Contractor for free, personalized MIPS support. Your Technical Assistance Contractor can be found here.
76. We had a new provider join our practice for 2020. How do we make sure our reporting for her is calculated under our group?
When you sign into the QPP Portal at https://qpp.cms.gov/login, you will be able to see who CMS has determined as part of your practice. If a new clinician is joining your practice, the clinician should register their HARP account under your practice’s Tax Identification Number (TIN). You can determine the new provider’s eligibility status using the QPP NPI Lookup Tool. Please be sure to check your providers’ eligibility status after each determination period to confirm their MIPS eligibility status. CMS tries to update the QPP NPI Lookup Tool as quickly as possible after the conclusion of the determination period. CMS will review past and current Medicare Part B Claims and PECOS data for each combination of individual NPI and Tax Identification Number (TIN) to make eligibility determinations. The MIPS determination period for 2019 consists of the two 12-month segments:
Segment #1: A 12-month segment beginning on October 1, 2017 and ending on September 30, 2018, plus a 30-day claims run out; and
Segment #2: A 12-month segment beginning on October 1, 2018 and ending on September 30, 2019. Segment #2 does not include a claims run out period.
Data from the 2 segments is then reconciled and released as the final eligibility determination. A final review of participation data takes place in the last three months of the year, from the end of Segment #2 until the end of the Performance Year. If a clinician starts billing Medicare Part B Claims under a practice's Taxpayer Identification Number (TIN) during that period, they:
Will be considered exempt and receive no payment adjustment, or;
Will receive the group score and payment adjustment if their TIN submits their Quality Payment Program data as part of a group.
For more information or assistance, please contact your region’s Technical Assistance Contractor by visiting https://qpp.cms.gov/about/small-underserved-rural-practices.
77. Can we claim an exclusion on both of the HIE measures? If yes, where would the scores be sent to? The Health Information Exchange objective includes the Support Electronic Referral Loops by Sending Health Information measure and the Support Electronic Referral Loops by Receiving and Incorporating Health Information measure. For the Support Electronic Referral Loops by Receiving and Incorporating Health Information measure, exclusions are available to:
Any MIPS eligible clinician who is unable to implement the measure for a MIPS performance period in 2019; OR
Any MIPS eligible clinician who receives transitions of care or referrals or has patient encounters in which the MIPS eligible clinician has never before encountered the patient fewer than 100 times.
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For the Support Electronic Referral Loops by Sending Health Information measure, exclusions are available to any MIPS eligible clinician who transfers a patient to another setting or refers a patient fewer than 100 times during the performance period. If you meet and claim the Support Electronic Referral Loops by Receiving and Incorporating Health Information measure’s exclusion, the 20 points are redistributed to the Support Electronic Referral Loops by Sending Health Information measure, making the measure worth a total of 40 points. For more details on each Promoting Interoperability measure, please see the 2019 Promoting Interoperability Measure Specifications.
78. Can we claim an exclusion of the Public Health Registry Reporting? If so, where would the score be sent to? To meet the Public Health Registry Reporting measure, the MIPS eligible clinician must be in active engagement with a public health agency to submit data to public health registries. Any MIPS eligible clinician meeting one or more of the following criteria may be excluded from the Public Health Reporting measure if the MIPS eligible clinician:
Does not diagnose or directly treat any disease or condition associated with a public health registry in the MIPS eligible clinician’s jurisdiction during the performance period. OR
Operates in a jurisdiction for which no public health agency is capable of accepting electronic registry transactions in the specific standards required to meet the CEHRT definition at the start of the performance period. OR
Operates in a jurisdiction where no public health registry for which the MIPS eligible clinician is eligible has declared readiness to receive electronic registry transactions as of 6 months prior to the start of the performance period.
For more details on each Promoting Interoperability measure, please see the 2019 Promoting Interoperability Measure Specifications. For more information or assistance, please contact your region’s Technical Assistance Contractor here.
79. In what time frame from the patient’s visit, can we give them access to their records/portal to still count for MIPS? One of the available Promoting Interoperability measures is Provide Patients Electronic Access to Their Health Information. This measure requires that for at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT). CMS defines “timely access” in this context as within 4 business days of the information being available to the MIPS eligible clinician. All Performing Interoperability measures must be met by the final day of the performance period. The final day of the 2019 performance period was December 31, 2019, so it is too late to earn credit for the Provide Patients Electronic access to
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their Health Information measure. For more information on this measure and other Promoting Interoperability measures, please review the 2019 Promoting Interoperability Measure Specifications.
80. How can we be more successful at closing the referral loop with so few HISP email addresses on file? There are both Quality and Promoting Interoperability category measures whose purpose is to promote the closing of referral loops. Quality Measure #374 Closing the Referral Loop: Receipt of Specialist Report measures the percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred. The manner in which the referring provider receives the report is not specified. If no HISP email is on file for the provider to whom the patient was referred, the referring provider may seek an alternative means of receiving the report, such as contacting the provider by phone, or use of Certified Electronic Health Record Technology (CEHRT). Promoting Interoperability Activity PI_HIE_4: Support Electronic Referral Loops By Receiving and Incorporating Health Information, and Activity PI_HIE_1 Support Electronic Referral Loops By Sending Health Information both require the use of CEHRT. Different CEHRTs may have different means of establishing bidirectional communication between practices and providers. If you are struggling with how to perform well in this measure, we recommended that you reach out to your EHR vendor to find out what kind of information you EHR is able to send.
Certified Electronic Health Record Technology (CEHRT): 81. What’s the best way to communicate the importance to EHR vendors to keep their ONC CHPL
information current as some don’t have current information? On CHPL, the eCQMs are outdated and can't generate a 2015 CEHRT ID, and their mandatory disclosure URL reflects on error. These are just a few of the issues. CMS and the Office of the National Coordinator for Health Information Technology (ONC) established standards and criteria for structured data that Electronic Health Records (EHRs) must meet in order to qualify for MIPS Promoting Interoperability. The ONC certifies vendor products each year under the Certified Electronic Health Record Technology (CEHRT) requirements and criteria. Sometimes a vendor fails to meet the requirements in a given year and is required to take corrective action or may be decertified. To find out which EHR systems meet the CEHRT requirements, please see the Certified Health IT Product List (CHPL) on the ONC website. If you believe your CEHRT is functioning incorrectly, you may file an official complaint. Additional information on the Certified Health IT Complaint process is available here. Clinician or groups may also submit a Promoting Interoperability (PI) Hardship Exception Application, citing one of the following reasons for review and approval:
MIPS eligible clinician in a small practice
MIPS eligible clinician using decertified EHR technology
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Insufficient Internet connectivity
Extreme and uncontrollable circumstances
Lack of control over the availability of CEHRT
If you receive an exception for the PI category, the PI category would receive a 0 weight in calculating your final score, and the 25% is reallocated to the Quality category, making the Quality category worth 70 points. More detailed information on PI can be found on the QPP website.
Please contact your local Technical Assistance Contractor for help reporting for the Promoting Interoperability category. Information for your region’s Technical Assistance Contractor can be found here.
82. What do we do if an EHR vendor, who asserts that they have 2015 CEHRT, cannot generate a 2015 CEHRT ID for the Promoting Interoperability category for 2019 reporting? CMS and the Office of the National Coordinator for Health Information Technology (ONC) established standards and criteria for structured data that Electronic Health Records (EHRs) must meet in order to qualify for MIPS Promoting Interoperability. The ONC certifies vendor products each year under the Certified Electronic Health Record Technology (CEHRT) requirements and criteria. Sometimes a vendor fails to meet the requirements in a given year and is required to take corrective action or may be decertified. To find out which EHR systems meet the CEHRT requirements, please see the Certified Health IT Product List (CHPL) on the ONC website. If you believe your CEHRT is functioning incorrectly, you may file an official complaint. Additional information on the Certified Health IT Complaint process is available here. Clinician or groups may also submit a Promoting Interoperability (PI) Hardship Exception Application, citing one of the following reasons for review and approval:
MIPS eligible clinician in a small practice
MIPS eligible clinician using decertified EHR technology
Insufficient Internet connectivity
Extreme and uncontrollable circumstances
Lack of control over the availability of CEHRT
Please note that the PI Hardship Exception Application for Performance Year 2019 closed on December 31, 2019. If you receive an exception for the PI category, the PI category would receive a 0 weight in calculating your final score, and the 25% is reallocated to the Quality category, making the Quality category worth 70 points. More detailed information on PI can be found on the QPP website.
83. Can you clarify whether the small practice exception is available only for providers who do not have an EHR or if it is available for any small practice? Lacking Certified Electronic Health Record Technology (CEHRT) does not necessarily qualify MIPS eligible clinicians for re-weighting of the Promoting Interoperability category. MIPS eligible
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clinicians, groups, and virtual groups may submit a Promoting Interoperability Hardship Exception Application citing one of the following specified reasons:
MIPS eligible clinician in a small practice
MIPS eligible clinician using decertified EHR technology
Insufficient Internet connectivity
Extreme and uncontrollable circumstances
Lack of control over the availability of CEHRT
Please note that the PI Hardship Exception Application for Performance Year 2019 closed on December 31, 2019. If you receive an exception for the PI category, the PI category would receive a 0 weight in calculating your final score, and the 25% is reallocated to the Quality category, making the Quality category worth 70 points. More detailed information on PI can be found on the QPP website.
84. What happens if medical practice switches from non-certified EHR to a certified EHR? Switching to a certified EHR could help you with reporting MIPS data and being successful in the Promoting Interoperability category. To get a score in the Promoting Interoperability category, you need to have used a certified EHR technology (CEHRT) for 90 consecutive days. If you do not meet that requirement, and you are part of a small practice (15 or fewer eligible clinicians), you can apply for a hardship exception. Unfortunately, the hardship exception application period has ended for the 2019 performance period, but you can apply in 2020. For more information about hardship exceptions, please visit the QPP Exceptions webpage. For free, personalized assistance with reporting to the MIPS program, please reach out to your region’s Technical Assistance Contractor. You can find the contact information for your local Technical Assistance Contractor here.
Scoring: 85. Do your scores follow you from practice to practice as a physician’s assistant?
Yes, the MIPS scores and subsequent payment adjustments “follow” providers when they move to a different practice. For example, if a physician’s assistant reports data to the MIPS program for the 2019 Performance year as part of one practice, but then moves to a different practice and bills to the new practice in 2021, the MIPS score the physician’s assistant receives based on their 2019 data will determine a payment adjustment at their new practice in 2021.
86. We reported claims all year for 2019 and yet when we look at our QPP progress it is only giving us credit for one measure and we are doing six. Is CMS still calculating for 2019? We used the correct G codes. Quality measures reported via Medicare Part B claims have been submitted throughout the 2019 performance period. Sign in to qpp.cms.gov for your preliminary feedback on part B claims measure data processed to date. When you navigate to the Reporting Overview section of the QPP Portal, you should see the data and preliminary performance category scores for the data you submitted. CMS will update this feedback at the end of the submission period with claims
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processed by your Medicare Administrative Contractor (MAC) within the 60 day “run out” period after the end of the 2019 performance period. Please note that some special scoring considerations will be reflected in the QPP Portal as the information becomes available during the submission period. If submitting via claims, once you’ve submitted the claim form and included the QDC and other information to report your quality data via claims, you’ll need to review the information you receive back from the MAC in the Remittance Advice or the Explanation of Benefits to see if the data submission was valid and successful. If N620 is listed as a denial code on your remittance advice, it tells you that the QDC(s) are valid for the reporting period. You can read more about this is the 2019 Claims Data Submission Fact Sheet. CMS will provide you with final performance feedback in July 2020 based on the data you submitted for the 2019 Performance Year. If you have concerns about your data or submissions, we strongly recommend that you contact your Technical Assistance Contractor (TAC) for support. You can find the contact information for your region’s TAC here.
87. If relying on claims to do quality reporting, is it possible to see our score for 2019? Yes, the preliminary feedback data is available in the QPP Portal. Please see the answer to #7 for more information. For more information on Performance Feedback, please see the 2018 Performance Feedback FAQs.
88. Can you explain how the bonus points work and to which score they are applied? For the Quality performance category, MIPS eligible clinicians will receive 1 bonus point per measure for reporting their quality data directly from their CEHRT without any manual manipulation. This end-to-end reporting bonus is available to measures reported through the Direct, Log-in and Upload, and CMS Web Interface submission types. There are also bonus points for submitting additional measures including 1 bonus point for each additional high priority measure, and 2 bonus points for each additional outcome and patient experience measure. Bonus points will be added to clinicians’ Quality performance category achievement points and are capped at 10% of their Quality performance category denominator. Beginning in the 2019 Performance Year, six bonus points will be added to the numerator of the Quality performance category for MIPS eligible clinicians in small practices who submit data on at least 1 Quality measure. Additionally, MIPS eligible clinicians can earn up to 10 percentage points based on the rate of their improvement in the Quality performance category from the year before. For more information on bonus scoring for the Quality performance category, please see the 2019 MIPS Quality Performance Category Fact Sheet. For the Promoting Interoperability performance category, there are two option measures that clinicians or groups may choose to report to earn bonus points. These measures are the Query of Prescription Drug Monitoring Program (PDMP) and the Verify Opioid Treatment Agreement. The maximum bonus points a MIPS eligible clinician could earn is 5 points for each of the two measures. Beginning with the 2019 MIPS Performance Year, CMS is not awarding bonus points for completing improvement activities.
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Additionally, the Complex Patient Bonus is added to the MIPS final score based on the overall medical complexity and social risk for the patients treated by a clinician or group. When determining bonus points for the care of complex patients, CMS considers two indicators:
The medical complexity of the clinician or group’s Medicare patients as measured through average Hierarchical Condition Category (HCC) risk scores and
Social risk identified for your patients as measured through the proportion of patients with dual eligible status (qualified to receive both Medicare and Medicaid benefits).
For more information on scoring, please see the 2019 MIPS Scoring Guide.
89. What does it mean if you log in to the QPP website for "cost", and in 2018 it lists N/A? Only clinicians and groups who could be scored on at least one measure will see cost measure information in 2018 performance feedback. If you don’t see any cost measure details and see a score of “N/A” in the “final score at a glance” section, you or your group did not meet the case minimum for either cost measure and the weight for this performance category was reallocated to another performance category (typically Quality). For more information on 2018 performance feedback, please see the 2018 Performance Feedback FAQs.
90. Do we still have a small practice bonus for 2020? If yes, how many points? Yes, the small practice bonus still applies in the 2020 Performance Year. Beginning in 2020, the small practice bonus will be added to the Quality performance category, rather than to the overall MIPS score during the MIPS final score calculation. Beginning in the 2019 Performance Year, six bonus points will be added to the numerator of the Quality performance category for MIPS eligible clinicians in small practices who submit data on at least 1 Quality measure. For more information on the quality performance category please review the 2020 Quality Performance Category Quick Start Guide.
91. Could you please explain how to use the information on the Cost Category Performance Feedback report as it applies to the equation used to determine the score?
Performance feedback on 2019 MIPS performance period Cost performance category will be provided in the Summer of 2020. Performance feedback on 2018 MIPS performance period Cost performance category was made available in the Summer of 2019. CMS calculates the cost score by assigning 1 to 10 achievement points to each scored measure based on the MIPS eligible clinician or group’s performance on the measure compared to the performance period benchmark for that measure. CMS establishes a single, national benchmark for each Cost measure. Both MIPS cost measures are calculated using administrative claims. Cost data for the TPCC measure are based on Medicare-allowed charges for Medicare Part A and Medicare Part B claims during the performance period that were submitted by all providers for Medicare beneficiaries attributed to your TIN or TIN-NPI. For the MIPS MSPB measure, per episode costs are based on Medicare Part A and Medicare Part B allowed amounts surrounding specific inpatient hospital stays for episodes attributed to you or your practice.
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CMS generates Hierarchical Conditions Categories (HCC) scores based on beneficiary characteristics and prior health conditions identified on previous Medicare claims. The HCC Percentile Ranking figure in the MIPS beneficiary-level TPCC and MSPB cost reports shows how the beneficiary’s risk score compares to all other Medicare Fee-for-Service beneficiaries nationwide, with 1 being low and 100 being high. Standardized Medicare allowed charges are using to compute the figures in the MIPS TPCC and MSPB beneficiary-level cost reports. These data associate a standardized amount with each actual allowed amount for each service billed by Medicare providers. The TPCC beneficiary-level cost report indicates which of your attributed beneficiaries had one or more of the following chronic conditions during the 2017 calendar year: diabetes, coronary artery disease, chronic obstructive pulmonary disease, and heart failure. For more detailed information on what is included in the Cost category feedback reports, please see the 2018 MIPS Performance Feedback Beneficiary-level Data Reports Supplement. The 2018 Performance Feedback FAQs also explains the different elements displayed in the Cost category feedback. We recommend that you speak with your regional Technical Assistance Contractor for assistance understanding and utilizing your performance feedback. You can locate their contact information here.
92. What is required to avoid a penalty?
To avoid receiving a negative payment adjustment, eligible clinicians must achieve 45 points during the 2020 Performance Period. This is an increase from the 2019 performance threshold of 30 points. To avoid the penalty, consider reporting on as many of the performance categories as possible. Plan to report at least six quality measures (or a complete specialty measure set) and select measures that will be easy for your practice to implement and document. Small practices can receive up to ten points per quality measure and will receive three points for measures that don’t meet data completeness requirements. Additionally, six points are automatically awarded to small practices who submit at least one quality measure. Small practices can receive 15 points in the Improvement Activity performance category by reporting one high-weighted improvement activity or two medium-weighted improvement activities. Keep in mind that small practices continue to have the option to apply for a hardship exception to the Promoting Interoperability performance category to have this category reweighted to zero. Keep these flexibilities in mind as you continue to report during the 2020 performance period.
93. If we submit exclusions, does it remove us from the ability to score enough points to receive
the payments?
Measure exclusions are available for clinicians to claim on select MIPS measures that may be difficult to report based on a practice’s volume of patients, electronic health record technology, or specialty. If measure exclusions are claimed, the points for excluded measures will be reallocated to other measures, making it possible to earn enough points to receive a positive payment adjustment. For more information on measure exclusions please see the 2020 Promoting Interoperability Measure Specifications.
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94. Will you get partial credit for meeting any part of MIPS?
It is possible to receive partial credit in MIPS. For the 2019 Performance Year, the Quality category accounts for 45% of your MIPS Final Score (maximum score of 60-100 points), the Cost category accounts for 15 of your MIPS Final Score (maximum score of 100 points), the Improvement category accounts for 15% of your MIPS Final Score (maximum score of 40 points), and the Promoting Interoperability accounts for 25% of your MIPS Final Score (maximum score of 100). Small practices qualify for flexibilities when it comes to MIPS reporting. For example:
Clinicians in small practices will continue to receive free, customized technical assistance to help them succeed in the QPP.
Solo practitioners and practices with 10 or fewer clinicians have the option to form a virtual group to participate with other practices.
Clinicians in small practices can continue submitting quality data for covered professional services at both the individual and group level through the Medicare Part B claims submission type for the Quality performance category.
For PY 2020, CMS will continue to award small practices 3 points for measures reported in the Quality performance category that don't meet data completeness requirements.
CMS will also continue to award 6 bonus points to the Quality performance category for small practices. These bonus points will be included as long as 1 quality measure is submitted.
Small practices can continue to apply to have the Promoting Interoperability Category reweighted to zero.
Small practices, and those in rural locations and in health professional shortage areas, have reduced reporting requirements for Improvement Activities:
o Medium-weighted activities are worth 20 points of the total Improvement Activity performance category score.
o High-weighted activities are worth 40 points of the total Improvement Activity performance category score.
95. When do we see results if we are doing it correctly? I thought PQRS would give us quarterly
updates. If you are eligible to report under the MIPS, you can log into the QPP Portal on the QPP website to preview your 2019 score based on your data submissions. Whether you are uploading your data directly to the QPP portal or a third-party vendor is submitting data on your behalf, it is important to log-in to your HARP account and review your MIPS data. For a step-by-step guide to signing up for a HARP account, refer to the “Register for a HARP Account” guide in the QPP Access User Guide. To see preliminary results for the 2020 reporting period, you may be able to obtain regular reports/dashboards through your EHR vendor, registry, ACO or APM entity, if you are reporting through one of those pathways. Some practices review these reports monthly or even weekly to make sure they are staying on track. If you are reporting via claims, you can review the information you receive back from your Medicare Administrative Contractor (MAC) in the Remittance Advice or the Explanation of
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Benefits to see if it the data submission was valid and successful. You can read more about the claims-based data submission process in the Claims Data Submission Fact Sheet. You can contact your region’s Technical Assistance Contractor for free personalized assistance. You can find the contact information for your local Technical Assistance Contractor here.
Payment Adjustments: 96. If a Physician’s Assistant reports as an individual, do the incentives, bonuses, and no penalty
benefit the practice or only the provider? MIPS payment adjustments are calculated based on each MIPS eligible clinician’s final score and are sent to the practice (TIN) that the clinician is part of. MIPS payment adjustments are applied to payments made for covered professional services, services for which payment is made under or based on the Medicare Physician Fee Schedule furnished by a MIPS eligible clinician. The payment adjustment is applied to the Medicare paid amount. MIPS payment adjustments are applied only to claims that are billed and paid on an assignment-related basis for covered professional services furnished by MIPS eligible clinicians.
97. When is the Medicare Sequestration payment deduction going to end? The Medicare Advantage Sequestration resulted in a mandatory two percent reduction in the Medicare Fee-for-Service program. The sequestration order covers all payments for services with dates of service or dates of discharge on or after April 1, 2013 and will continue until further notice.
98. Will the positive incentive eventually be eliminated? If yes, what year? CMS has not announced any plans to eliminate the MIPS program payment adjustment. As specified in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the maximum negative payment adjustment for the 2022 Payment Year and beyond is negative 9%. For more information on the MIPS program, please see the 2020 Quality Payment Program Final Rule.
