0

MIPS Small Practice Office Hours

Aiming for Success in 2018Lisa Gall DNP FNP LHIT-HP

Christopher Becker CPHIMS CPHITMona Mathews PMP

June 12 2018

1

Disclaimer

Content provided in this presentation is based on the latest information made available by the Centers for Medicare amp Medicaid Services (CMS) and is subject to change

CMS policies change so we encourage you to review specific statutes and regulations that may apply to you for interpretation and updates

2

QPP SURS Contractors

bull Stratis Health in Minnesota

bull MetaStar in Wisconsin

We are partners in the Quality Payment Program Resource Centerreg for the Midwest a Centers for Medicare and Medicaid Services-funded collaboration among 10 key partners across Michigan Ohio Indiana Illinois Kentucky Wisconsin and Minnesota focused on supporting providers in small practices and rural or underserved areas Our Resource Centerreg provides free assistance to eligible clinicians as they navigate participation in the Quality Payment Program

3

Objectives

bull Understand the basics of the Quality Payment Program (QPP)

bull Learn who is eligible to participate

bull Understand changes in 2018 QPP

bull Learn how to estimate your Merit-Based Incentive Payment System (MIPS) score to help you set improvement goals

2

QPP SURS Contractors

bull Stratis Health in Minnesota

bull MetaStar in Wisconsin

We are partners in the Quality Payment Program Resource Centerreg for the Midwest a Centers for Medicare and Medicaid Services-funded collaboration among 10 key partners across Michigan Ohio Indiana Illinois Kentucky Wisconsin and Minnesota focused on supporting providers in small practices and rural or underserved areas Our Resource Centerreg provides free assistance to eligible clinicians as they navigate participation in the Quality Payment Program

3

Objectives

bull Understand the basics of the Quality Payment Program (QPP)

bull Learn who is eligible to participate

bull Understand changes in 2018 QPP

bull Learn how to estimate your Merit-Based Incentive Payment System (MIPS) score to help you set improvement goals

Overview of the Quality Payment Program

5

Quality Payment Program

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

MIPSThe Merit-Based Incentive

Payment System (MIPS)

Performance-based payment adjustment

Advanced APMsAdvanced Alternative Payment

Models (Advanced APM)

Incentive payment for sufficiently participating in an innovative payment

model

6

CMS Considerations in Implementing QPP

Improve beneficiary outcomes

Reduce burden on clinicians

Increase adoption of Advanced APMs

Improve data and information sharing

Ensure operational excellence in program implementation

Maximize participation

Deliver Information Technology (IT) systems capabilities that meet the needs of users

7

MIPS Eligible Clinicians (EC)

Physicians Doctors of medicine osteopathy dental surgery dental medicine podiatric medicine or optometry and chiropractorsdagger

daggerWith respect to certain specified treatment a Doctor of Chiropractic legally authorized to practice by a State in which heshe performs this function

Physicians Nurse Practitioners

PhysicianAssistants

Clinical Nurse Specialists

Certified Registered Nurse Anesthetists

No change in the TYPES of clinicians eligible to participate in 2018

8

2018 Year 2 MIPS Eligible Clinicians

2017 Year 1

bull Bill gt $30000 Medicare Part B AND

bull Provide care to gt 100 beneficiaries

2018 Year 2

bull Bill gt $90000 to Medicare Part B AND

bull Provide care to gt 200 beneficiaries

Low-volume threshold for 2018 Year 2 changes to INCLUDE MIPS eligible clinicians billing more than $90000 a year in Medicare Part B allowed charges AND providing care for more than 200 Medicare patients a year

Voluntary reporting remains an option for clinicians exempt from MIPS

9

EligibilitySpecial Status Determination

Enter your 10-digit National Provider Identifier (NPI) number to view your MIPS participation status by Performance Year (PY)

QPP Participation Lookup Tool

6

CMS Considerations in Implementing QPP

Improve beneficiary outcomes

Reduce burden on clinicians

Increase adoption of Advanced APMs

Improve data and information sharing

Ensure operational excellence in program implementation

Maximize participation

Deliver Information Technology (IT) systems capabilities that meet the needs of users

7

MIPS Eligible Clinicians (EC)

Physicians Doctors of medicine osteopathy dental surgery dental medicine podiatric medicine or optometry and chiropractorsdagger

daggerWith respect to certain specified treatment a Doctor of Chiropractic legally authorized to practice by a State in which heshe performs this function

Physicians Nurse Practitioners

PhysicianAssistants

Clinical Nurse Specialists

Certified Registered Nurse Anesthetists

No change in the TYPES of clinicians eligible to participate in 2018

8

2018 Year 2 MIPS Eligible Clinicians

2017 Year 1

bull Bill gt $30000 Medicare Part B AND

bull Provide care to gt 100 beneficiaries

2018 Year 2

bull Bill gt $90000 to Medicare Part B AND

bull Provide care to gt 200 beneficiaries

Low-volume threshold for 2018 Year 2 changes to INCLUDE MIPS eligible clinicians billing more than $90000 a year in Medicare Part B allowed charges AND providing care for more than 200 Medicare patients a year

Voluntary reporting remains an option for clinicians exempt from MIPS

9

EligibilitySpecial Status Determination

Enter your 10-digit National Provider Identifier (NPI) number to view your MIPS participation status by Performance Year (PY)

QPP Participation Lookup Tool

8

2018 Year 2 MIPS Eligible Clinicians

2017 Year 1

bull Bill gt $30000 Medicare Part B AND

bull Provide care to gt 100 beneficiaries

2018 Year 2

bull Bill gt $90000 to Medicare Part B AND

bull Provide care to gt 200 beneficiaries

Low-volume threshold for 2018 Year 2 changes to INCLUDE MIPS eligible clinicians billing more than $90000 a year in Medicare Part B allowed charges AND providing care for more than 200 Medicare patients a year

Voluntary reporting remains an option for clinicians exempt from MIPS

9

EligibilitySpecial Status Determination

Enter your 10-digit National Provider Identifier (NPI) number to view your MIPS participation status by Performance Year (PY)

QPP Participation Lookup Tool

10

EligibilitySpecial Status Lookup Results

11

No Change in Basic MIPS Exemption Criteria

1 First year enrolled in Medicare

2 Significantly Participating in an Advanced APM

25 percent of Medicare payments paid through Advanced APM

20 percent of Medicare beneficiaries seen through Advanced APM

3 Low Volume Threshold

Exempt if either lt $90000 billed OR lt 200 visits during determination period (in either of 2 prior billing years)

Determined at (Tax Identification Number (TIN)National Provider Identifier (NPI)) for individuals AND

At the group (TIN) for groups

12

MIPS 2018 Year 2 Special Status (Special Scoring)

Special scoring in Improvement Activities (IA) category for some (small underserved rural non-patient facing hospital-based) and bonuses for others (small practices)

No change to non-patient facing (NPF) Criteria

bull Individuals - lt100 patient facing encounters

bull Groups - gt75 of clinicians in group are NPF

No changes to Special Status

bull Zip code of practice designated small (15 or less) rural or Health Professional Shortage Area (HPSA)

bull Group more than 75 of NPIs billing under the individual MIPS eligible clinician or grouprsquos TIN

13

2018 Reporting Options

Clinicians participating as a group are assessed as a group across all four MIPS performance categories The same is true for clinicians participating as a virtual group

Source httpswwwcmsgovMedicareQuality-Payment-ProgramResource-LibraryQPP-Year-2-Final-Rule-NPC-Slidespdf

12

MIPS 2018 Year 2 Special Status (Special Scoring)

Special scoring in Improvement Activities (IA) category for some (small underserved rural non-patient facing hospital-based) and bonuses for others (small practices)

No change to non-patient facing (NPF) Criteria

bull Individuals - lt100 patient facing encounters

bull Groups - gt75 of clinicians in group are NPF

No changes to Special Status

bull Zip code of practice designated small (15 or less) rural or Health Professional Shortage Area (HPSA)

bull Group more than 75 of NPIs billing under the individual MIPS eligible clinician or grouprsquos TIN

13

2018 Reporting Options

Clinicians participating as a group are assessed as a group across all four MIPS performance categories The same is true for clinicians participating as a virtual group

Source httpswwwcmsgovMedicareQuality-Payment-ProgramResource-LibraryQPP-Year-2-Final-Rule-NPC-Slidespdf

Two Paths for QPP MIPS and APMs

Path One APMs

Advanced APMs and MIPS APMs

15

Path One Advanced Alternative Payment Models (APMs)

Alternative Payment Models

New models of paying for health care that incentivize quality and value over volume by moving away from traditional Medicare Part B Physician Fee Service

Advanced APMs

Subset of APMs that receive a 5 percent bonus payments if ECs meet thresholds to become Qualified Participants (QPs)

Three statutory requirements1 Participants must use certified electronic health record (EHR) technology2 Payment for covered services based on quality measures comparable to MIPS3 Entity is either bull a Medical Home Model expanded under CMS Innovation Center authority

ORbull Requires participants to bear more than a nominal amount of financial risk

16

APM

Advanced

APMs

APM

MIPS APM

MIPS

What Are MIPS APMs

Middle ground between reporting to MIPS and being a full-fledged

Advanced APM

Examples

bull ECs in Advanced APMs who donrsquot meet thresholds for Advanced APM

bull Medicare Shared Savings Program (MSSP) Track 1 (Upside risk no

downside risk)

MIPS Eligible CliniciansQualified

Participants

MIPS Eligible

Clinicians

Two Paths for QPP

Path Two MIPSMerit-Based Incentive Payment System

18

Path Two Merit-Based Incentive Payment System (MIPS)

Previous Category ndash

Year

Physician Quality Reporting System

(PQRS)

Value Based Modifier (VBM)

ImprovementActivities

EHR Incentive Program

2018 50 10 15 25

2017 60 0 15 25Source CMS Quality Payment Program ndash Train-the-Trainer

4 MIPS category scores compiled for

MIPS final score worth up to 100 points

Quality Improvement

Activities

Promoting

Interoperability Cost

MIPS Quality category

20

Quality Category 50 of MIPS Score in 2018

Earn up to 60 Quality Category points

bull Earn category points on up to six of 277 measures

bull May pick from specialty set bull Must include at least 1 outcome or high priority measure

bull Earn 1 -10 category points for measures with benchmarks

bull Large practice floor score - earn 1 point if data completeness not metbull Small practice floor score - still earn 3 points

bull 6 measures are ldquotopped outrdquo (have little room for improvement)

bull Maximum 7 pointsbull Must meet data completeness (gt60) to earn more than floor score

bull Bonus points for reporting

bull End to end electronically (eCQM) bull Additional outcome or high priority measures

21

Quality Category 50 of MIPS Score in 2018

New Scoring Improvement Bonus - Worth up to 10 points

bull Based on improvements in total category score

bull Higher improvement results in more points

MIPS Reporting methods

bull Claims EHR Registry Qualified Clinical Data Registry (QCDR) - 60 category points

bull Each reporting method has different benchmarks

MIPS Cost category

23

Cost 10 of MIPS Score in 2018

Category Performance Score included starting in 2018

bull Two measure scores are averaged (or any one available)

bull Medicare Spending per Beneficiary (MSPB)

bull Total per capita cost measures

bull Category score weight will increase to 30 percent by 2021

bull No data submission required

bull Benchmark calculated using current year performance

bull New Scoring Improvement Bonus up to one percentage point

MIPS Improvement Activities (IA) Category

25

Improvement Activities 15 of MIPS Score in 2018

Maximum Category score 40 points

bull Prepare to transition to APMs and Medical Home Models

bull Engage in up to four activities for at least 90 days

bull Medium activity = 10 points bull High activity = 20 points bull Additional activities available in 2018 some changed

bull Earn PI category Bonus points for using CEHRT for some IA

bull YesNo attestation

Special Scoring

bull Full credit (40 pts) ECs in PCMH MSSP Next Generation APM

bull Half credit (20 pts) clinicians in other APMs

bull Double points clinicians in small or rural settings non-patient facing

Path Two MIPS

Promoting Interoperability(PI) category

27

Promoting Interoperability 25 of MIPS Score in 2018

Maximum Category score 100 of 155 possible points

bull Earn up to 25 MIPS POINTS

bull 2018 ndash May use either 2014 or 2015 Certified EHR Technology (or combination)

bull 10 bonus for using only 2015 CERHT

Base measures ndash Required for any score in PI category

bull Earn up to 50 points

bull 4 measures for 2014 CEHRT 5 for 2015 CEHRT

bull Exclusions for 2-3 base measures e-prescribing and HIE send summary of care for 20142015 CEHRT receive summary of care for 2015 CEHRT

Performance measures Optional

bull Earn up to 90 points

bull 7 for 2014 CEHRT 9 for 2015 CEHRT

28

Promoting Interoperability 25 of MIPS Score

Bonus points

bull Earn up to 25 in 2018 bull Use 2015 Certified EHR Technology exclusively - 10

bull Use CEHRT for at least 1 IAndash 10

bull Report to one Public Health or clinical registry - 10

bull Report to any additional PH or clinical registry ndash 5

29

PI automatically reweighted to quality

- unless EC reports PI

1 MIPS EC types NP CNS CRNA PA

2 Some ldquoSpecial Statusrdquo (SS) MIPS ECsbull Non-patient facing le 100 Medicare B patient-encounters

bull Hospital-based gt75 encounters in hospital setting

- inpatient on-campus outpatient hospital or ED (POS 21-23)

- Off campus Outpatient Hospitals (POS 19)

- Ambulatory Surgical Center (POS 24)

3 Groups with gt 75 of clinicians meeting SS

Reweighting PI Category Points to Quality

30

When Can PI Category Be Reweighted to Quality

PI is NOT automatically reweighted to quality for these types of MIPS ECsndash EC must apply for hardship exception

1 Clinicians in small practices

2 EHR decertified

3 Significant Hardship exception (5 year limit removed)

4 CMS designated Natural disasters (FEMA)

31

2014 vs 2015 Certified EHR

Four Base Measures = 50 pointsSeven Performance Measures

bull Earn up to 10 points each

bull Two worth 20 points each (Summary of Care Access)

Five Base Measures = 50 pointsNine Performance Measures

bull Earn up to 10 points each

2

0

1

4

C

E

H

R

T

MEASURE NAME

Security Risk Analysis (Base)

e-Prescribing (Base)

Send Summary of Care (Base and Performance)

Provide Patient Access (Base and Performance)

Immunization Registry Reporting

Medication Reconciliation

Patient-Specific Education

Secure Messaging

View Download or Transmit (VDT)

Specialized Registry Reporting

Syndromic Surveillance Reporting

2

0

1

5

C

E

H

R

T

MEASURE NAME

Security Risk Analysis (Base)

e-Prescribing (Base)

Send Summary of Care (Base and Performance)

RequestAccept Summary of Care (Base and Performance)

Provide Patient Access (Base and Performance)

Clinical Information Reconciliation

Patient-generated Health Data

Immunization Registry Reporting

Patient-Specific Education

Secure Messaging

View Download or Transmit (VDT)

Clinical Data Registry Reporting

Public Health Registry Reporting

Electronic Case Reporting

Syndromic Surveillance ReportingOpportunity to reach 155 points with bonuses but maximum category score is 100

MIPS Scoring and Reporting

33

Performance Period 2017 - 2018

Promoting

Interoperability

Source CMS Quality Payment Program ndash Train-The-Trainer

34

MIPS 2018 Year 2 Scoring (0-100 Points)

ge70 points Eligible for positive payment adjustment and exceptional performance bonus payment

1599 ndash 6999 points Positive payment adjustment No exceptional performance bonus payment No negative payment adjustment

15 points Neutral payment adjustment

376 ndash 1499 points Negative payment adjustment ranges from -49 percent to - 01percent

0 - 375 points -5 percent payment adjustment

Modified from CMS Quality Payment Program ndash Train-The-Trainer

Increase in performance threshold and payment adjustment

35

New Bonuses in 2018

Bonus eligibility Must report on at least one MIPS category

Bonus added to final MIPS Score

1 Complex Patient Bonus

Up to five bonus points for treating complex patients Score based on

bull Hierarchical Condition Category (HCC) risk score +

bull Percentage of dual eligible beneficiaries

2 Small Practice Bonus

Five bonus points added to final score of any MIPS eligible clinician or group in a small practice (15 or fewer clinicians)

Steps to Success in the Quality Payment Program

37

Steps to Success in the QPP

Determine Eligible Clinicians

Determine path

bull APM (group) or

bull MIPS (individual or group)

Collect data

bull Promoting Interoperability

bull Quality measures

bull Improvement activities

38

EIDM Account Set Up

To login and submit data clinicians will use their Enterprise Identity Management (EIDM) credentials

bull The EIDM account provides CMS customers with a single user identification they can use to access many CMS systems

bull The system will connect each user with their practice Taxpayer Identification Number (TIN) Once connected clinicians will be able to report data for the practice as a group or for individual clinicians within the practice

bull To learn about how to create an EIDM account see this user guide

bull Quick Start Guide

39

Clinicians Steps to Success in the QPP - continued

Review current performance

bull Foster performance improvement

bull Choose reporting periods for PI and IA

bull 90 ndash 365 days

bull Full calendar year for quality reporting

bull Evaluate available reporting methods

bull Choose group or individual performance

Contact QPP Resource Center for assistance

16

APM

Advanced

APMs

APM

MIPS APM

MIPS

What Are MIPS APMs

Middle ground between reporting to MIPS and being a full-fledged

Advanced APM

Examples

bull ECs in Advanced APMs who donrsquot meet thresholds for Advanced APM

bull Medicare Shared Savings Program (MSSP) Track 1 (Upside risk no

downside risk)

MIPS Eligible CliniciansQualified

Participants

MIPS Eligible

Clinicians

Two Paths for QPP

Path Two MIPSMerit-Based Incentive Payment System

18

Path Two Merit-Based Incentive Payment System (MIPS)

Previous Category ndash

Year

Physician Quality Reporting System

(PQRS)

Value Based Modifier (VBM)

ImprovementActivities

EHR Incentive Program

2018 50 10 15 25

2017 60 0 15 25Source CMS Quality Payment Program ndash Train-the-Trainer

4 MIPS category scores compiled for

MIPS final score worth up to 100 points

Quality Improvement

Activities

Promoting

Interoperability Cost

MIPS Quality category

20

Quality Category 50 of MIPS Score in 2018

Earn up to 60 Quality Category points

bull Earn category points on up to six of 277 measures

bull May pick from specialty set bull Must include at least 1 outcome or high priority measure

bull Earn 1 -10 category points for measures with benchmarks

bull Large practice floor score - earn 1 point if data completeness not metbull Small practice floor score - still earn 3 points

bull 6 measures are ldquotopped outrdquo (have little room for improvement)

bull Maximum 7 pointsbull Must meet data completeness (gt60) to earn more than floor score

bull Bonus points for reporting

bull End to end electronically (eCQM) bull Additional outcome or high priority measures

21

Quality Category 50 of MIPS Score in 2018

New Scoring Improvement Bonus - Worth up to 10 points

bull Based on improvements in total category score

bull Higher improvement results in more points

MIPS Reporting methods

bull Claims EHR Registry Qualified Clinical Data Registry (QCDR) - 60 category points

bull Each reporting method has different benchmarks

MIPS Cost category

23

Cost 10 of MIPS Score in 2018

Category Performance Score included starting in 2018

bull Two measure scores are averaged (or any one available)

bull Medicare Spending per Beneficiary (MSPB)

bull Total per capita cost measures

bull Category score weight will increase to 30 percent by 2021

bull No data submission required

bull Benchmark calculated using current year performance

bull New Scoring Improvement Bonus up to one percentage point

MIPS Improvement Activities (IA) Category

25

Improvement Activities 15 of MIPS Score in 2018

Maximum Category score 40 points

bull Prepare to transition to APMs and Medical Home Models

bull Engage in up to four activities for at least 90 days

bull Medium activity = 10 points bull High activity = 20 points bull Additional activities available in 2018 some changed

bull Earn PI category Bonus points for using CEHRT for some IA

bull YesNo attestation

Special Scoring

bull Full credit (40 pts) ECs in PCMH MSSP Next Generation APM

bull Half credit (20 pts) clinicians in other APMs

bull Double points clinicians in small or rural settings non-patient facing

Path Two MIPS

Promoting Interoperability(PI) category

27

Promoting Interoperability 25 of MIPS Score in 2018

Maximum Category score 100 of 155 possible points

bull Earn up to 25 MIPS POINTS

bull 2018 ndash May use either 2014 or 2015 Certified EHR Technology (or combination)

bull 10 bonus for using only 2015 CERHT

Base measures ndash Required for any score in PI category

bull Earn up to 50 points

bull 4 measures for 2014 CEHRT 5 for 2015 CEHRT

bull Exclusions for 2-3 base measures e-prescribing and HIE send summary of care for 20142015 CEHRT receive summary of care for 2015 CEHRT

Performance measures Optional

bull Earn up to 90 points

bull 7 for 2014 CEHRT 9 for 2015 CEHRT

28

Promoting Interoperability 25 of MIPS Score

Bonus points

bull Earn up to 25 in 2018 bull Use 2015 Certified EHR Technology exclusively - 10

bull Use CEHRT for at least 1 IAndash 10

bull Report to one Public Health or clinical registry - 10

bull Report to any additional PH or clinical registry ndash 5

29

PI automatically reweighted to quality

- unless EC reports PI

1 MIPS EC types NP CNS CRNA PA

2 Some ldquoSpecial Statusrdquo (SS) MIPS ECsbull Non-patient facing le 100 Medicare B patient-encounters

bull Hospital-based gt75 encounters in hospital setting

- inpatient on-campus outpatient hospital or ED (POS 21-23)

- Off campus Outpatient Hospitals (POS 19)

- Ambulatory Surgical Center (POS 24)

3 Groups with gt 75 of clinicians meeting SS

Reweighting PI Category Points to Quality

30

When Can PI Category Be Reweighted to Quality

PI is NOT automatically reweighted to quality for these types of MIPS ECsndash EC must apply for hardship exception

1 Clinicians in small practices

2 EHR decertified

3 Significant Hardship exception (5 year limit removed)

4 CMS designated Natural disasters (FEMA)

31

2014 vs 2015 Certified EHR

Four Base Measures = 50 pointsSeven Performance Measures

bull Earn up to 10 points each

bull Two worth 20 points each (Summary of Care Access)

Five Base Measures = 50 pointsNine Performance Measures

bull Earn up to 10 points each

2

0

1

4

C

E

H

R

T

MEASURE NAME

Security Risk Analysis (Base)

e-Prescribing (Base)

Send Summary of Care (Base and Performance)

Provide Patient Access (Base and Performance)

Immunization Registry Reporting

Medication Reconciliation

Patient-Specific Education

Secure Messaging

View Download or Transmit (VDT)

Specialized Registry Reporting

Syndromic Surveillance Reporting

2

0

1

5

C

E

H

R

T

MEASURE NAME

Security Risk Analysis (Base)

e-Prescribing (Base)

Send Summary of Care (Base and Performance)

RequestAccept Summary of Care (Base and Performance)

Provide Patient Access (Base and Performance)

Clinical Information Reconciliation

Patient-generated Health Data

Immunization Registry Reporting

Patient-Specific Education

Secure Messaging

View Download or Transmit (VDT)

Clinical Data Registry Reporting

Public Health Registry Reporting

Electronic Case Reporting

Syndromic Surveillance ReportingOpportunity to reach 155 points with bonuses but maximum category score is 100

MIPS Scoring and Reporting

33

Performance Period 2017 - 2018

Promoting

Interoperability

Source CMS Quality Payment Program ndash Train-The-Trainer

34

MIPS 2018 Year 2 Scoring (0-100 Points)

ge70 points Eligible for positive payment adjustment and exceptional performance bonus payment

1599 ndash 6999 points Positive payment adjustment No exceptional performance bonus payment No negative payment adjustment

15 points Neutral payment adjustment

376 ndash 1499 points Negative payment adjustment ranges from -49 percent to - 01percent

0 - 375 points -5 percent payment adjustment

Modified from CMS Quality Payment Program ndash Train-The-Trainer

Increase in performance threshold and payment adjustment

35

New Bonuses in 2018

Bonus eligibility Must report on at least one MIPS category

Bonus added to final MIPS Score

1 Complex Patient Bonus

Up to five bonus points for treating complex patients Score based on

bull Hierarchical Condition Category (HCC) risk score +

bull Percentage of dual eligible beneficiaries

2 Small Practice Bonus

Five bonus points added to final score of any MIPS eligible clinician or group in a small practice (15 or fewer clinicians)

Steps to Success in the Quality Payment Program

37

Steps to Success in the QPP

Determine Eligible Clinicians

Determine path

bull APM (group) or

bull MIPS (individual or group)

Collect data

bull Promoting Interoperability

bull Quality measures

bull Improvement activities

38

EIDM Account Set Up

To login and submit data clinicians will use their Enterprise Identity Management (EIDM) credentials

bull The EIDM account provides CMS customers with a single user identification they can use to access many CMS systems

bull The system will connect each user with their practice Taxpayer Identification Number (TIN) Once connected clinicians will be able to report data for the practice as a group or for individual clinicians within the practice

bull To learn about how to create an EIDM account see this user guide

bull Quick Start Guide

39

Clinicians Steps to Success in the QPP - continued

Review current performance

bull Foster performance improvement

bull Choose reporting periods for PI and IA

bull 90 ndash 365 days

bull Full calendar year for quality reporting

bull Evaluate available reporting methods

bull Choose group or individual performance

Contact QPP Resource Center for assistance

18

Path Two Merit-Based Incentive Payment System (MIPS)

Previous Category ndash

Year

Physician Quality Reporting System

(PQRS)

Value Based Modifier (VBM)

ImprovementActivities

EHR Incentive Program

2018 50 10 15 25

2017 60 0 15 25Source CMS Quality Payment Program ndash Train-the-Trainer

4 MIPS category scores compiled for

MIPS final score worth up to 100 points

Quality Improvement

Activities

Promoting

Interoperability Cost

MIPS Quality category

20

Quality Category 50 of MIPS Score in 2018

Earn up to 60 Quality Category points

bull Earn category points on up to six of 277 measures

bull May pick from specialty set bull Must include at least 1 outcome or high priority measure

bull Earn 1 -10 category points for measures with benchmarks

bull Large practice floor score - earn 1 point if data completeness not metbull Small practice floor score - still earn 3 points

bull 6 measures are ldquotopped outrdquo (have little room for improvement)

bull Maximum 7 pointsbull Must meet data completeness (gt60) to earn more than floor score

bull Bonus points for reporting

bull End to end electronically (eCQM) bull Additional outcome or high priority measures

21

Quality Category 50 of MIPS Score in 2018

New Scoring Improvement Bonus - Worth up to 10 points

bull Based on improvements in total category score

bull Higher improvement results in more points

MIPS Reporting methods

bull Claims EHR Registry Qualified Clinical Data Registry (QCDR) - 60 category points

bull Each reporting method has different benchmarks

MIPS Cost category

23

Cost 10 of MIPS Score in 2018

Category Performance Score included starting in 2018

bull Two measure scores are averaged (or any one available)

bull Medicare Spending per Beneficiary (MSPB)

bull Total per capita cost measures

bull Category score weight will increase to 30 percent by 2021

bull No data submission required

bull Benchmark calculated using current year performance

bull New Scoring Improvement Bonus up to one percentage point

MIPS Improvement Activities (IA) Category

25

Improvement Activities 15 of MIPS Score in 2018

Maximum Category score 40 points

bull Prepare to transition to APMs and Medical Home Models

bull Engage in up to four activities for at least 90 days

bull Medium activity = 10 points bull High activity = 20 points bull Additional activities available in 2018 some changed

bull Earn PI category Bonus points for using CEHRT for some IA

bull YesNo attestation

Special Scoring

bull Full credit (40 pts) ECs in PCMH MSSP Next Generation APM

bull Half credit (20 pts) clinicians in other APMs

bull Double points clinicians in small or rural settings non-patient facing

Path Two MIPS

Promoting Interoperability(PI) category

27

Promoting Interoperability 25 of MIPS Score in 2018

Maximum Category score 100 of 155 possible points

bull Earn up to 25 MIPS POINTS

bull 2018 ndash May use either 2014 or 2015 Certified EHR Technology (or combination)

bull 10 bonus for using only 2015 CERHT

Base measures ndash Required for any score in PI category

bull Earn up to 50 points

bull 4 measures for 2014 CEHRT 5 for 2015 CEHRT

bull Exclusions for 2-3 base measures e-prescribing and HIE send summary of care for 20142015 CEHRT receive summary of care for 2015 CEHRT

Performance measures Optional

bull Earn up to 90 points

bull 7 for 2014 CEHRT 9 for 2015 CEHRT

28

Promoting Interoperability 25 of MIPS Score

Bonus points

bull Earn up to 25 in 2018 bull Use 2015 Certified EHR Technology exclusively - 10

bull Use CEHRT for at least 1 IAndash 10

bull Report to one Public Health or clinical registry - 10

bull Report to any additional PH or clinical registry ndash 5

29

PI automatically reweighted to quality

- unless EC reports PI

1 MIPS EC types NP CNS CRNA PA

2 Some ldquoSpecial Statusrdquo (SS) MIPS ECsbull Non-patient facing le 100 Medicare B patient-encounters

bull Hospital-based gt75 encounters in hospital setting

- inpatient on-campus outpatient hospital or ED (POS 21-23)

- Off campus Outpatient Hospitals (POS 19)

- Ambulatory Surgical Center (POS 24)

3 Groups with gt 75 of clinicians meeting SS

Reweighting PI Category Points to Quality

30

When Can PI Category Be Reweighted to Quality

PI is NOT automatically reweighted to quality for these types of MIPS ECsndash EC must apply for hardship exception

1 Clinicians in small practices

2 EHR decertified

3 Significant Hardship exception (5 year limit removed)

4 CMS designated Natural disasters (FEMA)

31

2014 vs 2015 Certified EHR

Four Base Measures = 50 pointsSeven Performance Measures

bull Earn up to 10 points each

bull Two worth 20 points each (Summary of Care Access)

Five Base Measures = 50 pointsNine Performance Measures

bull Earn up to 10 points each

2

0

1

4

C

E

H

R

T

MEASURE NAME

Security Risk Analysis (Base)

e-Prescribing (Base)

Send Summary of Care (Base and Performance)

Provide Patient Access (Base and Performance)

Immunization Registry Reporting

Medication Reconciliation

Patient-Specific Education

Secure Messaging

View Download or Transmit (VDT)

Specialized Registry Reporting

Syndromic Surveillance Reporting

2

0

1

5

C

E

H

R

T

MEASURE NAME

Security Risk Analysis (Base)

e-Prescribing (Base)

Send Summary of Care (Base and Performance)

RequestAccept Summary of Care (Base and Performance)

Provide Patient Access (Base and Performance)

Clinical Information Reconciliation

Patient-generated Health Data

Immunization Registry Reporting

Patient-Specific Education

Secure Messaging

View Download or Transmit (VDT)

Clinical Data Registry Reporting

Public Health Registry Reporting

Electronic Case Reporting

Syndromic Surveillance ReportingOpportunity to reach 155 points with bonuses but maximum category score is 100

MIPS Scoring and Reporting

33

Performance Period 2017 - 2018

Promoting

Interoperability

Source CMS Quality Payment Program ndash Train-The-Trainer

34

MIPS 2018 Year 2 Scoring (0-100 Points)

ge70 points Eligible for positive payment adjustment and exceptional performance bonus payment

1599 ndash 6999 points Positive payment adjustment No exceptional performance bonus payment No negative payment adjustment

15 points Neutral payment adjustment

376 ndash 1499 points Negative payment adjustment ranges from -49 percent to - 01percent

0 - 375 points -5 percent payment adjustment

Modified from CMS Quality Payment Program ndash Train-The-Trainer

Increase in performance threshold and payment adjustment

35

New Bonuses in 2018

Bonus eligibility Must report on at least one MIPS category

Bonus added to final MIPS Score

1 Complex Patient Bonus

Up to five bonus points for treating complex patients Score based on

bull Hierarchical Condition Category (HCC) risk score +

bull Percentage of dual eligible beneficiaries

2 Small Practice Bonus

Five bonus points added to final score of any MIPS eligible clinician or group in a small practice (15 or fewer clinicians)

Steps to Success in the Quality Payment Program

37

Steps to Success in the QPP

Determine Eligible Clinicians

Determine path

bull APM (group) or

bull MIPS (individual or group)

Collect data

bull Promoting Interoperability

bull Quality measures

bull Improvement activities

38

EIDM Account Set Up

To login and submit data clinicians will use their Enterprise Identity Management (EIDM) credentials

bull The EIDM account provides CMS customers with a single user identification they can use to access many CMS systems

bull The system will connect each user with their practice Taxpayer Identification Number (TIN) Once connected clinicians will be able to report data for the practice as a group or for individual clinicians within the practice

bull To learn about how to create an EIDM account see this user guide

bull Quick Start Guide

39

Clinicians Steps to Success in the QPP - continued

Review current performance

bull Foster performance improvement

bull Choose reporting periods for PI and IA

bull 90 ndash 365 days

bull Full calendar year for quality reporting

bull Evaluate available reporting methods

bull Choose group or individual performance

Contact QPP Resource Center for assistance

20

Quality Category 50 of MIPS Score in 2018

Earn up to 60 Quality Category points

bull Earn category points on up to six of 277 measures

bull May pick from specialty set bull Must include at least 1 outcome or high priority measure

bull Earn 1 -10 category points for measures with benchmarks

bull Large practice floor score - earn 1 point if data completeness not metbull Small practice floor score - still earn 3 points

bull 6 measures are ldquotopped outrdquo (have little room for improvement)

bull Maximum 7 pointsbull Must meet data completeness (gt60) to earn more than floor score

bull Bonus points for reporting

bull End to end electronically (eCQM) bull Additional outcome or high priority measures

21

Quality Category 50 of MIPS Score in 2018

New Scoring Improvement Bonus - Worth up to 10 points

bull Based on improvements in total category score

bull Higher improvement results in more points

MIPS Reporting methods

bull Claims EHR Registry Qualified Clinical Data Registry (QCDR) - 60 category points

bull Each reporting method has different benchmarks

MIPS Cost category

23

Cost 10 of MIPS Score in 2018

Category Performance Score included starting in 2018

bull Two measure scores are averaged (or any one available)

bull Medicare Spending per Beneficiary (MSPB)

bull Total per capita cost measures

bull Category score weight will increase to 30 percent by 2021

bull No data submission required

bull Benchmark calculated using current year performance

bull New Scoring Improvement Bonus up to one percentage point

MIPS Improvement Activities (IA) Category

25

Improvement Activities 15 of MIPS Score in 2018

Maximum Category score 40 points

bull Prepare to transition to APMs and Medical Home Models

bull Engage in up to four activities for at least 90 days

bull Medium activity = 10 points bull High activity = 20 points bull Additional activities available in 2018 some changed

bull Earn PI category Bonus points for using CEHRT for some IA

bull YesNo attestation

Special Scoring

bull Full credit (40 pts) ECs in PCMH MSSP Next Generation APM

bull Half credit (20 pts) clinicians in other APMs

bull Double points clinicians in small or rural settings non-patient facing

Path Two MIPS

Promoting Interoperability(PI) category

27

Promoting Interoperability 25 of MIPS Score in 2018

Maximum Category score 100 of 155 possible points

bull Earn up to 25 MIPS POINTS

bull 2018 ndash May use either 2014 or 2015 Certified EHR Technology (or combination)

bull 10 bonus for using only 2015 CERHT

Base measures ndash Required for any score in PI category

bull Earn up to 50 points

bull 4 measures for 2014 CEHRT 5 for 2015 CEHRT

bull Exclusions for 2-3 base measures e-prescribing and HIE send summary of care for 20142015 CEHRT receive summary of care for 2015 CEHRT

Performance measures Optional

bull Earn up to 90 points

bull 7 for 2014 CEHRT 9 for 2015 CEHRT

28

Promoting Interoperability 25 of MIPS Score

Bonus points

bull Earn up to 25 in 2018 bull Use 2015 Certified EHR Technology exclusively - 10

bull Use CEHRT for at least 1 IAndash 10

bull Report to one Public Health or clinical registry - 10

bull Report to any additional PH or clinical registry ndash 5

29

PI automatically reweighted to quality

- unless EC reports PI

1 MIPS EC types NP CNS CRNA PA

2 Some ldquoSpecial Statusrdquo (SS) MIPS ECsbull Non-patient facing le 100 Medicare B patient-encounters

bull Hospital-based gt75 encounters in hospital setting

- inpatient on-campus outpatient hospital or ED (POS 21-23)

- Off campus Outpatient Hospitals (POS 19)

- Ambulatory Surgical Center (POS 24)

3 Groups with gt 75 of clinicians meeting SS

Reweighting PI Category Points to Quality

30

When Can PI Category Be Reweighted to Quality

PI is NOT automatically reweighted to quality for these types of MIPS ECsndash EC must apply for hardship exception

1 Clinicians in small practices

2 EHR decertified

3 Significant Hardship exception (5 year limit removed)

4 CMS designated Natural disasters (FEMA)

31

2014 vs 2015 Certified EHR

Four Base Measures = 50 pointsSeven Performance Measures

bull Earn up to 10 points each

bull Two worth 20 points each (Summary of Care Access)

Five Base Measures = 50 pointsNine Performance Measures

bull Earn up to 10 points each

2

0

1

4

C

E

H

R

T

MEASURE NAME

Security Risk Analysis (Base)

e-Prescribing (Base)

Send Summary of Care (Base and Performance)

Provide Patient Access (Base and Performance)

Immunization Registry Reporting

Medication Reconciliation

Patient-Specific Education

Secure Messaging

View Download or Transmit (VDT)

Specialized Registry Reporting

Syndromic Surveillance Reporting

2

0

1

5

C

E

H

R

T

MEASURE NAME

Security Risk Analysis (Base)

e-Prescribing (Base)

Send Summary of Care (Base and Performance)

RequestAccept Summary of Care (Base and Performance)

Provide Patient Access (Base and Performance)

Clinical Information Reconciliation

Patient-generated Health Data

Immunization Registry Reporting

Patient-Specific Education

Secure Messaging

View Download or Transmit (VDT)

Clinical Data Registry Reporting

Public Health Registry Reporting

Electronic Case Reporting

Syndromic Surveillance ReportingOpportunity to reach 155 points with bonuses but maximum category score is 100

MIPS Scoring and Reporting

33

Performance Period 2017 - 2018

Promoting

Interoperability

Source CMS Quality Payment Program ndash Train-The-Trainer

34

MIPS 2018 Year 2 Scoring (0-100 Points)

ge70 points Eligible for positive payment adjustment and exceptional performance bonus payment

1599 ndash 6999 points Positive payment adjustment No exceptional performance bonus payment No negative payment adjustment

15 points Neutral payment adjustment

376 ndash 1499 points Negative payment adjustment ranges from -49 percent to - 01percent

0 - 375 points -5 percent payment adjustment

Modified from CMS Quality Payment Program ndash Train-The-Trainer

Increase in performance threshold and payment adjustment

35

New Bonuses in 2018

Bonus eligibility Must report on at least one MIPS category

Bonus added to final MIPS Score

1 Complex Patient Bonus

Up to five bonus points for treating complex patients Score based on

bull Hierarchical Condition Category (HCC) risk score +

bull Percentage of dual eligible beneficiaries

2 Small Practice Bonus

Five bonus points added to final score of any MIPS eligible clinician or group in a small practice (15 or fewer clinicians)

Steps to Success in the Quality Payment Program

37

Steps to Success in the QPP

Determine Eligible Clinicians

Determine path

bull APM (group) or

bull MIPS (individual or group)

Collect data

bull Promoting Interoperability

bull Quality measures

bull Improvement activities

38

EIDM Account Set Up

To login and submit data clinicians will use their Enterprise Identity Management (EIDM) credentials

bull The EIDM account provides CMS customers with a single user identification they can use to access many CMS systems

bull The system will connect each user with their practice Taxpayer Identification Number (TIN) Once connected clinicians will be able to report data for the practice as a group or for individual clinicians within the practice

bull To learn about how to create an EIDM account see this user guide

bull Quick Start Guide

39

Clinicians Steps to Success in the QPP - continued

Review current performance

bull Foster performance improvement

bull Choose reporting periods for PI and IA

bull 90 ndash 365 days

bull Full calendar year for quality reporting

bull Evaluate available reporting methods

bull Choose group or individual performance

Contact QPP Resource Center for assistance

MIPS Cost category

23

Cost 10 of MIPS Score in 2018

Category Performance Score included starting in 2018

bull Two measure scores are averaged (or any one available)

bull Medicare Spending per Beneficiary (MSPB)

bull Total per capita cost measures

bull Category score weight will increase to 30 percent by 2021

bull No data submission required

bull Benchmark calculated using current year performance

bull New Scoring Improvement Bonus up to one percentage point

MIPS Improvement Activities (IA) Category

25

Improvement Activities 15 of MIPS Score in 2018

Maximum Category score 40 points

bull Prepare to transition to APMs and Medical Home Models

bull Engage in up to four activities for at least 90 days

bull Medium activity = 10 points bull High activity = 20 points bull Additional activities available in 2018 some changed

bull Earn PI category Bonus points for using CEHRT for some IA

bull YesNo attestation

Special Scoring

bull Full credit (40 pts) ECs in PCMH MSSP Next Generation APM

bull Half credit (20 pts) clinicians in other APMs

bull Double points clinicians in small or rural settings non-patient facing

Path Two MIPS

Promoting Interoperability(PI) category

27

Promoting Interoperability 25 of MIPS Score in 2018

Maximum Category score 100 of 155 possible points

bull Earn up to 25 MIPS POINTS

bull 2018 ndash May use either 2014 or 2015 Certified EHR Technology (or combination)

bull 10 bonus for using only 2015 CERHT

Base measures ndash Required for any score in PI category

bull Earn up to 50 points

bull 4 measures for 2014 CEHRT 5 for 2015 CEHRT

bull Exclusions for 2-3 base measures e-prescribing and HIE send summary of care for 20142015 CEHRT receive summary of care for 2015 CEHRT

Performance measures Optional

bull Earn up to 90 points

bull 7 for 2014 CEHRT 9 for 2015 CEHRT

28

Promoting Interoperability 25 of MIPS Score

Bonus points

bull Earn up to 25 in 2018 bull Use 2015 Certified EHR Technology exclusively - 10

bull Use CEHRT for at least 1 IAndash 10

bull Report to one Public Health or clinical registry - 10

bull Report to any additional PH or clinical registry ndash 5

29

PI automatically reweighted to quality

- unless EC reports PI

1 MIPS EC types NP CNS CRNA PA

2 Some ldquoSpecial Statusrdquo (SS) MIPS ECsbull Non-patient facing le 100 Medicare B patient-encounters

bull Hospital-based gt75 encounters in hospital setting

- inpatient on-campus outpatient hospital or ED (POS 21-23)

- Off campus Outpatient Hospitals (POS 19)

- Ambulatory Surgical Center (POS 24)

3 Groups with gt 75 of clinicians meeting SS

Reweighting PI Category Points to Quality

30

When Can PI Category Be Reweighted to Quality

PI is NOT automatically reweighted to quality for these types of MIPS ECsndash EC must apply for hardship exception

1 Clinicians in small practices

2 EHR decertified

3 Significant Hardship exception (5 year limit removed)

4 CMS designated Natural disasters (FEMA)

31

2014 vs 2015 Certified EHR

Four Base Measures = 50 pointsSeven Performance Measures

bull Earn up to 10 points each

bull Two worth 20 points each (Summary of Care Access)

Five Base Measures = 50 pointsNine Performance Measures

bull Earn up to 10 points each

2

0

1

4

C

E

H

R

T

MEASURE NAME

Security Risk Analysis (Base)

e-Prescribing (Base)

Send Summary of Care (Base and Performance)

Provide Patient Access (Base and Performance)

Immunization Registry Reporting

Medication Reconciliation

Patient-Specific Education

Secure Messaging

View Download or Transmit (VDT)

Specialized Registry Reporting

Syndromic Surveillance Reporting

2

0

1

5

C

E

H

R

T

MEASURE NAME

Security Risk Analysis (Base)

e-Prescribing (Base)

Send Summary of Care (Base and Performance)

RequestAccept Summary of Care (Base and Performance)

Provide Patient Access (Base and Performance)

Clinical Information Reconciliation

Patient-generated Health Data

Immunization Registry Reporting

Patient-Specific Education

Secure Messaging

View Download or Transmit (VDT)

Clinical Data Registry Reporting

Public Health Registry Reporting

Electronic Case Reporting

Syndromic Surveillance ReportingOpportunity to reach 155 points with bonuses but maximum category score is 100

MIPS Scoring and Reporting

33

Performance Period 2017 - 2018

Promoting

Interoperability

Source CMS Quality Payment Program ndash Train-The-Trainer

34

MIPS 2018 Year 2 Scoring (0-100 Points)

ge70 points Eligible for positive payment adjustment and exceptional performance bonus payment

1599 ndash 6999 points Positive payment adjustment No exceptional performance bonus payment No negative payment adjustment

15 points Neutral payment adjustment

376 ndash 1499 points Negative payment adjustment ranges from -49 percent to - 01percent

0 - 375 points -5 percent payment adjustment

Modified from CMS Quality Payment Program ndash Train-The-Trainer

Increase in performance threshold and payment adjustment

35

New Bonuses in 2018

Bonus eligibility Must report on at least one MIPS category

Bonus added to final MIPS Score

1 Complex Patient Bonus

Up to five bonus points for treating complex patients Score based on

bull Hierarchical Condition Category (HCC) risk score +

bull Percentage of dual eligible beneficiaries

2 Small Practice Bonus

Five bonus points added to final score of any MIPS eligible clinician or group in a small practice (15 or fewer clinicians)

Steps to Success in the Quality Payment Program

37

Steps to Success in the QPP

Determine Eligible Clinicians

Determine path

bull APM (group) or

bull MIPS (individual or group)

Collect data

bull Promoting Interoperability

bull Quality measures

bull Improvement activities

38

EIDM Account Set Up

To login and submit data clinicians will use their Enterprise Identity Management (EIDM) credentials

bull The EIDM account provides CMS customers with a single user identification they can use to access many CMS systems

bull The system will connect each user with their practice Taxpayer Identification Number (TIN) Once connected clinicians will be able to report data for the practice as a group or for individual clinicians within the practice

bull To learn about how to create an EIDM account see this user guide

bull Quick Start Guide

39

Clinicians Steps to Success in the QPP - continued

Review current performance

bull Foster performance improvement

bull Choose reporting periods for PI and IA

bull 90 ndash 365 days

bull Full calendar year for quality reporting

bull Evaluate available reporting methods

bull Choose group or individual performance

Contact QPP Resource Center for assistance

MIPS Improvement Activities (IA) Category

25

Improvement Activities 15 of MIPS Score in 2018

Maximum Category score 40 points

bull Prepare to transition to APMs and Medical Home Models

bull Engage in up to four activities for at least 90 days

bull Medium activity = 10 points bull High activity = 20 points bull Additional activities available in 2018 some changed

bull Earn PI category Bonus points for using CEHRT for some IA

bull YesNo attestation

Special Scoring

bull Full credit (40 pts) ECs in PCMH MSSP Next Generation APM

bull Half credit (20 pts) clinicians in other APMs

bull Double points clinicians in small or rural settings non-patient facing

Path Two MIPS

Promoting Interoperability(PI) category

27

Promoting Interoperability 25 of MIPS Score in 2018

Maximum Category score 100 of 155 possible points

bull Earn up to 25 MIPS POINTS

bull 2018 ndash May use either 2014 or 2015 Certified EHR Technology (or combination)

bull 10 bonus for using only 2015 CERHT

Base measures ndash Required for any score in PI category

bull Earn up to 50 points

bull 4 measures for 2014 CEHRT 5 for 2015 CEHRT

bull Exclusions for 2-3 base measures e-prescribing and HIE send summary of care for 20142015 CEHRT receive summary of care for 2015 CEHRT

Performance measures Optional

bull Earn up to 90 points

bull 7 for 2014 CEHRT 9 for 2015 CEHRT

28

Promoting Interoperability 25 of MIPS Score

Bonus points

bull Earn up to 25 in 2018 bull Use 2015 Certified EHR Technology exclusively - 10

bull Use CEHRT for at least 1 IAndash 10

bull Report to one Public Health or clinical registry - 10

bull Report to any additional PH or clinical registry ndash 5

29

PI automatically reweighted to quality

- unless EC reports PI

1 MIPS EC types NP CNS CRNA PA

2 Some ldquoSpecial Statusrdquo (SS) MIPS ECsbull Non-patient facing le 100 Medicare B patient-encounters

bull Hospital-based gt75 encounters in hospital setting

- inpatient on-campus outpatient hospital or ED (POS 21-23)

- Off campus Outpatient Hospitals (POS 19)

- Ambulatory Surgical Center (POS 24)

3 Groups with gt 75 of clinicians meeting SS

Reweighting PI Category Points to Quality

30

When Can PI Category Be Reweighted to Quality

PI is NOT automatically reweighted to quality for these types of MIPS ECsndash EC must apply for hardship exception

1 Clinicians in small practices

2 EHR decertified

3 Significant Hardship exception (5 year limit removed)

4 CMS designated Natural disasters (FEMA)

31

2014 vs 2015 Certified EHR

Four Base Measures = 50 pointsSeven Performance Measures

bull Earn up to 10 points each

bull Two worth 20 points each (Summary of Care Access)

Five Base Measures = 50 pointsNine Performance Measures

bull Earn up to 10 points each

2

0

1

4

C

E

H

R

T

MEASURE NAME

Security Risk Analysis (Base)

e-Prescribing (Base)

Send Summary of Care (Base and Performance)

Provide Patient Access (Base and Performance)

Immunization Registry Reporting

Medication Reconciliation

Patient-Specific Education

Secure Messaging

View Download or Transmit (VDT)

Specialized Registry Reporting

Syndromic Surveillance Reporting

2

0

1

5

C

E

H

R

T

MEASURE NAME

Security Risk Analysis (Base)

e-Prescribing (Base)

Send Summary of Care (Base and Performance)

RequestAccept Summary of Care (Base and Performance)

Provide Patient Access (Base and Performance)

Clinical Information Reconciliation

Patient-generated Health Data

Immunization Registry Reporting

Patient-Specific Education

Secure Messaging

View Download or Transmit (VDT)

Clinical Data Registry Reporting

Public Health Registry Reporting

Electronic Case Reporting

Syndromic Surveillance ReportingOpportunity to reach 155 points with bonuses but maximum category score is 100

MIPS Scoring and Reporting

33

Performance Period 2017 - 2018

Promoting

Interoperability

Source CMS Quality Payment Program ndash Train-The-Trainer

34

MIPS 2018 Year 2 Scoring (0-100 Points)

ge70 points Eligible for positive payment adjustment and exceptional performance bonus payment

1599 ndash 6999 points Positive payment adjustment No exceptional performance bonus payment No negative payment adjustment

15 points Neutral payment adjustment

376 ndash 1499 points Negative payment adjustment ranges from -49 percent to - 01percent

0 - 375 points -5 percent payment adjustment

Modified from CMS Quality Payment Program ndash Train-The-Trainer

Increase in performance threshold and payment adjustment

35

New Bonuses in 2018

Bonus eligibility Must report on at least one MIPS category

Bonus added to final MIPS Score

1 Complex Patient Bonus

Up to five bonus points for treating complex patients Score based on

bull Hierarchical Condition Category (HCC) risk score +

bull Percentage of dual eligible beneficiaries

2 Small Practice Bonus

Five bonus points added to final score of any MIPS eligible clinician or group in a small practice (15 or fewer clinicians)

Steps to Success in the Quality Payment Program

37

Steps to Success in the QPP

Determine Eligible Clinicians

Determine path

bull APM (group) or

bull MIPS (individual or group)

Collect data

bull Promoting Interoperability

bull Quality measures

bull Improvement activities

38

EIDM Account Set Up

To login and submit data clinicians will use their Enterprise Identity Management (EIDM) credentials

bull The EIDM account provides CMS customers with a single user identification they can use to access many CMS systems

bull The system will connect each user with their practice Taxpayer Identification Number (TIN) Once connected clinicians will be able to report data for the practice as a group or for individual clinicians within the practice

bull To learn about how to create an EIDM account see this user guide

bull Quick Start Guide

39

Clinicians Steps to Success in the QPP - continued

Review current performance

bull Foster performance improvement

bull Choose reporting periods for PI and IA

bull 90 ndash 365 days

bull Full calendar year for quality reporting

bull Evaluate available reporting methods

bull Choose group or individual performance

Contact QPP Resource Center for assistance

Path Two MIPS

Promoting Interoperability(PI) category

27

Promoting Interoperability 25 of MIPS Score in 2018

Maximum Category score 100 of 155 possible points

bull Earn up to 25 MIPS POINTS

bull 2018 ndash May use either 2014 or 2015 Certified EHR Technology (or combination)

bull 10 bonus for using only 2015 CERHT

Base measures ndash Required for any score in PI category

bull Earn up to 50 points

bull 4 measures for 2014 CEHRT 5 for 2015 CEHRT

bull Exclusions for 2-3 base measures e-prescribing and HIE send summary of care for 20142015 CEHRT receive summary of care for 2015 CEHRT

Performance measures Optional

bull Earn up to 90 points

bull 7 for 2014 CEHRT 9 for 2015 CEHRT

28

Promoting Interoperability 25 of MIPS Score

Bonus points

bull Earn up to 25 in 2018 bull Use 2015 Certified EHR Technology exclusively - 10

bull Use CEHRT for at least 1 IAndash 10

bull Report to one Public Health or clinical registry - 10

bull Report to any additional PH or clinical registry ndash 5

29

PI automatically reweighted to quality

- unless EC reports PI

1 MIPS EC types NP CNS CRNA PA

2 Some ldquoSpecial Statusrdquo (SS) MIPS ECsbull Non-patient facing le 100 Medicare B patient-encounters

bull Hospital-based gt75 encounters in hospital setting

- inpatient on-campus outpatient hospital or ED (POS 21-23)

- Off campus Outpatient Hospitals (POS 19)

- Ambulatory Surgical Center (POS 24)

3 Groups with gt 75 of clinicians meeting SS

Reweighting PI Category Points to Quality

30

When Can PI Category Be Reweighted to Quality

PI is NOT automatically reweighted to quality for these types of MIPS ECsndash EC must apply for hardship exception

1 Clinicians in small practices

2 EHR decertified

3 Significant Hardship exception (5 year limit removed)

4 CMS designated Natural disasters (FEMA)

31

2014 vs 2015 Certified EHR

Four Base Measures = 50 pointsSeven Performance Measures

bull Earn up to 10 points each

bull Two worth 20 points each (Summary of Care Access)

Five Base Measures = 50 pointsNine Performance Measures

bull Earn up to 10 points each

2

0

1

4

C

E

H

R

T

MEASURE NAME

Security Risk Analysis (Base)

e-Prescribing (Base)

Send Summary of Care (Base and Performance)

Provide Patient Access (Base and Performance)

Immunization Registry Reporting

Medication Reconciliation

Patient-Specific Education

Secure Messaging

View Download or Transmit (VDT)

Specialized Registry Reporting

Syndromic Surveillance Reporting

2

0

1

5

C

E

H

R

T

MEASURE NAME

Security Risk Analysis (Base)

e-Prescribing (Base)

Send Summary of Care (Base and Performance)

RequestAccept Summary of Care (Base and Performance)

Provide Patient Access (Base and Performance)

Clinical Information Reconciliation

Patient-generated Health Data

Immunization Registry Reporting

Patient-Specific Education

Secure Messaging

View Download or Transmit (VDT)

Clinical Data Registry Reporting

Public Health Registry Reporting

Electronic Case Reporting

Syndromic Surveillance ReportingOpportunity to reach 155 points with bonuses but maximum category score is 100

MIPS Scoring and Reporting

33

Performance Period 2017 - 2018

Promoting

Interoperability

Source CMS Quality Payment Program ndash Train-The-Trainer

34

MIPS 2018 Year 2 Scoring (0-100 Points)

ge70 points Eligible for positive payment adjustment and exceptional performance bonus payment

1599 ndash 6999 points Positive payment adjustment No exceptional performance bonus payment No negative payment adjustment

15 points Neutral payment adjustment

376 ndash 1499 points Negative payment adjustment ranges from -49 percent to - 01percent

0 - 375 points -5 percent payment adjustment

Modified from CMS Quality Payment Program ndash Train-The-Trainer

Increase in performance threshold and payment adjustment

35

New Bonuses in 2018

Bonus eligibility Must report on at least one MIPS category

Bonus added to final MIPS Score

1 Complex Patient Bonus

Up to five bonus points for treating complex patients Score based on

bull Hierarchical Condition Category (HCC) risk score +

bull Percentage of dual eligible beneficiaries

2 Small Practice Bonus

Five bonus points added to final score of any MIPS eligible clinician or group in a small practice (15 or fewer clinicians)

Steps to Success in the Quality Payment Program

37

Steps to Success in the QPP

Determine Eligible Clinicians

Determine path

bull APM (group) or

bull MIPS (individual or group)

Collect data

bull Promoting Interoperability

bull Quality measures

bull Improvement activities

38

EIDM Account Set Up

To login and submit data clinicians will use their Enterprise Identity Management (EIDM) credentials

bull The EIDM account provides CMS customers with a single user identification they can use to access many CMS systems

bull The system will connect each user with their practice Taxpayer Identification Number (TIN) Once connected clinicians will be able to report data for the practice as a group or for individual clinicians within the practice

bull To learn about how to create an EIDM account see this user guide

bull Quick Start Guide

39

Clinicians Steps to Success in the QPP - continued

Review current performance

bull Foster performance improvement

bull Choose reporting periods for PI and IA

bull 90 ndash 365 days

bull Full calendar year for quality reporting

bull Evaluate available reporting methods

bull Choose group or individual performance

Contact QPP Resource Center for assistance

28

Promoting Interoperability 25 of MIPS Score

Bonus points

bull Earn up to 25 in 2018 bull Use 2015 Certified EHR Technology exclusively - 10

bull Use CEHRT for at least 1 IAndash 10

bull Report to one Public Health or clinical registry - 10

bull Report to any additional PH or clinical registry ndash 5

29

PI automatically reweighted to quality

- unless EC reports PI

1 MIPS EC types NP CNS CRNA PA

2 Some ldquoSpecial Statusrdquo (SS) MIPS ECsbull Non-patient facing le 100 Medicare B patient-encounters

bull Hospital-based gt75 encounters in hospital setting

- inpatient on-campus outpatient hospital or ED (POS 21-23)

- Off campus Outpatient Hospitals (POS 19)

- Ambulatory Surgical Center (POS 24)

3 Groups with gt 75 of clinicians meeting SS

Reweighting PI Category Points to Quality

30

When Can PI Category Be Reweighted to Quality

PI is NOT automatically reweighted to quality for these types of MIPS ECsndash EC must apply for hardship exception

1 Clinicians in small practices

2 EHR decertified

3 Significant Hardship exception (5 year limit removed)

4 CMS designated Natural disasters (FEMA)

31

2014 vs 2015 Certified EHR

Four Base Measures = 50 pointsSeven Performance Measures

bull Earn up to 10 points each

bull Two worth 20 points each (Summary of Care Access)

Five Base Measures = 50 pointsNine Performance Measures

bull Earn up to 10 points each

2

0

1

4

C

E

H

R

T

MEASURE NAME

Security Risk Analysis (Base)

e-Prescribing (Base)

Send Summary of Care (Base and Performance)

Provide Patient Access (Base and Performance)

Immunization Registry Reporting

Medication Reconciliation

Patient-Specific Education

Secure Messaging

View Download or Transmit (VDT)

Specialized Registry Reporting

Syndromic Surveillance Reporting

2

0

1

5

C

E

H

R

T

MEASURE NAME

Security Risk Analysis (Base)

e-Prescribing (Base)

Send Summary of Care (Base and Performance)

RequestAccept Summary of Care (Base and Performance)

Provide Patient Access (Base and Performance)

Clinical Information Reconciliation

Patient-generated Health Data

Immunization Registry Reporting

Patient-Specific Education

Secure Messaging

View Download or Transmit (VDT)

Clinical Data Registry Reporting

Public Health Registry Reporting

Electronic Case Reporting

Syndromic Surveillance ReportingOpportunity to reach 155 points with bonuses but maximum category score is 100

MIPS Scoring and Reporting

33

Performance Period 2017 - 2018

Promoting

Interoperability

Source CMS Quality Payment Program ndash Train-The-Trainer

34

MIPS 2018 Year 2 Scoring (0-100 Points)

ge70 points Eligible for positive payment adjustment and exceptional performance bonus payment

1599 ndash 6999 points Positive payment adjustment No exceptional performance bonus payment No negative payment adjustment

15 points Neutral payment adjustment

376 ndash 1499 points Negative payment adjustment ranges from -49 percent to - 01percent

0 - 375 points -5 percent payment adjustment

Modified from CMS Quality Payment Program ndash Train-The-Trainer

Increase in performance threshold and payment adjustment

35

New Bonuses in 2018

Bonus eligibility Must report on at least one MIPS category

Bonus added to final MIPS Score

1 Complex Patient Bonus

Up to five bonus points for treating complex patients Score based on

bull Hierarchical Condition Category (HCC) risk score +

bull Percentage of dual eligible beneficiaries

2 Small Practice Bonus

Five bonus points added to final score of any MIPS eligible clinician or group in a small practice (15 or fewer clinicians)

Steps to Success in the Quality Payment Program

37

Steps to Success in the QPP

Determine Eligible Clinicians

Determine path

bull APM (group) or

bull MIPS (individual or group)

Collect data

bull Promoting Interoperability

bull Quality measures

bull Improvement activities

38

EIDM Account Set Up

To login and submit data clinicians will use their Enterprise Identity Management (EIDM) credentials

bull The EIDM account provides CMS customers with a single user identification they can use to access many CMS systems

bull The system will connect each user with their practice Taxpayer Identification Number (TIN) Once connected clinicians will be able to report data for the practice as a group or for individual clinicians within the practice

bull To learn about how to create an EIDM account see this user guide

bull Quick Start Guide

39

Clinicians Steps to Success in the QPP - continued

Review current performance

bull Foster performance improvement

bull Choose reporting periods for PI and IA

bull 90 ndash 365 days

bull Full calendar year for quality reporting

bull Evaluate available reporting methods

bull Choose group or individual performance

Contact QPP Resource Center for assistance

30

When Can PI Category Be Reweighted to Quality

PI is NOT automatically reweighted to quality for these types of MIPS ECsndash EC must apply for hardship exception

1 Clinicians in small practices

2 EHR decertified

3 Significant Hardship exception (5 year limit removed)

4 CMS designated Natural disasters (FEMA)

31

2014 vs 2015 Certified EHR

Four Base Measures = 50 pointsSeven Performance Measures

bull Earn up to 10 points each

bull Two worth 20 points each (Summary of Care Access)

Five Base Measures = 50 pointsNine Performance Measures

bull Earn up to 10 points each

2

0

1

4

C

E

H

R

T

MEASURE NAME

Security Risk Analysis (Base)

e-Prescribing (Base)

Send Summary of Care (Base and Performance)

Provide Patient Access (Base and Performance)

Immunization Registry Reporting

Medication Reconciliation

Patient-Specific Education

Secure Messaging

View Download or Transmit (VDT)

Specialized Registry Reporting

Syndromic Surveillance Reporting

2

0

1

5

C

E

H

R

T

MEASURE NAME

Security Risk Analysis (Base)

e-Prescribing (Base)

Send Summary of Care (Base and Performance)

RequestAccept Summary of Care (Base and Performance)

Provide Patient Access (Base and Performance)

Clinical Information Reconciliation

Patient-generated Health Data

Immunization Registry Reporting

Patient-Specific Education

Secure Messaging

View Download or Transmit (VDT)

Clinical Data Registry Reporting

Public Health Registry Reporting

Electronic Case Reporting

Syndromic Surveillance ReportingOpportunity to reach 155 points with bonuses but maximum category score is 100

MIPS Scoring and Reporting

33

Performance Period 2017 - 2018

Promoting

Interoperability

Source CMS Quality Payment Program ndash Train-The-Trainer

34

MIPS 2018 Year 2 Scoring (0-100 Points)

ge70 points Eligible for positive payment adjustment and exceptional performance bonus payment

1599 ndash 6999 points Positive payment adjustment No exceptional performance bonus payment No negative payment adjustment

15 points Neutral payment adjustment

376 ndash 1499 points Negative payment adjustment ranges from -49 percent to - 01percent

0 - 375 points -5 percent payment adjustment

Modified from CMS Quality Payment Program ndash Train-The-Trainer

Increase in performance threshold and payment adjustment

35

New Bonuses in 2018

Bonus eligibility Must report on at least one MIPS category

Bonus added to final MIPS Score

1 Complex Patient Bonus

Up to five bonus points for treating complex patients Score based on

bull Hierarchical Condition Category (HCC) risk score +

bull Percentage of dual eligible beneficiaries

2 Small Practice Bonus

Five bonus points added to final score of any MIPS eligible clinician or group in a small practice (15 or fewer clinicians)

Steps to Success in the Quality Payment Program

37

Steps to Success in the QPP

Determine Eligible Clinicians

Determine path

bull APM (group) or

bull MIPS (individual or group)

Collect data

bull Promoting Interoperability

bull Quality measures

bull Improvement activities

38

EIDM Account Set Up

To login and submit data clinicians will use their Enterprise Identity Management (EIDM) credentials

bull The EIDM account provides CMS customers with a single user identification they can use to access many CMS systems

bull The system will connect each user with their practice Taxpayer Identification Number (TIN) Once connected clinicians will be able to report data for the practice as a group or for individual clinicians within the practice

bull To learn about how to create an EIDM account see this user guide

bull Quick Start Guide

39

Clinicians Steps to Success in the QPP - continued

Review current performance

bull Foster performance improvement

bull Choose reporting periods for PI and IA

bull 90 ndash 365 days

bull Full calendar year for quality reporting

bull Evaluate available reporting methods

bull Choose group or individual performance

Contact QPP Resource Center for assistance

MIPS Scoring and Reporting

33

Performance Period 2017 - 2018

Promoting

Interoperability

Source CMS Quality Payment Program ndash Train-The-Trainer

34

MIPS 2018 Year 2 Scoring (0-100 Points)

ge70 points Eligible for positive payment adjustment and exceptional performance bonus payment

1599 ndash 6999 points Positive payment adjustment No exceptional performance bonus payment No negative payment adjustment

15 points Neutral payment adjustment

376 ndash 1499 points Negative payment adjustment ranges from -49 percent to - 01percent

0 - 375 points -5 percent payment adjustment

Modified from CMS Quality Payment Program ndash Train-The-Trainer

Increase in performance threshold and payment adjustment

35

New Bonuses in 2018

Bonus eligibility Must report on at least one MIPS category

Bonus added to final MIPS Score

1 Complex Patient Bonus

Up to five bonus points for treating complex patients Score based on

bull Hierarchical Condition Category (HCC) risk score +

bull Percentage of dual eligible beneficiaries

2 Small Practice Bonus

Five bonus points added to final score of any MIPS eligible clinician or group in a small practice (15 or fewer clinicians)

Steps to Success in the Quality Payment Program

37

Steps to Success in the QPP

Determine Eligible Clinicians

Determine path

bull APM (group) or

bull MIPS (individual or group)

Collect data

bull Promoting Interoperability

bull Quality measures

bull Improvement activities

38

EIDM Account Set Up

To login and submit data clinicians will use their Enterprise Identity Management (EIDM) credentials

bull The EIDM account provides CMS customers with a single user identification they can use to access many CMS systems

bull The system will connect each user with their practice Taxpayer Identification Number (TIN) Once connected clinicians will be able to report data for the practice as a group or for individual clinicians within the practice

bull To learn about how to create an EIDM account see this user guide

bull Quick Start Guide

39

Clinicians Steps to Success in the QPP - continued

Review current performance

bull Foster performance improvement

bull Choose reporting periods for PI and IA

bull 90 ndash 365 days

bull Full calendar year for quality reporting

bull Evaluate available reporting methods

bull Choose group or individual performance

Contact QPP Resource Center for assistance

34

MIPS 2018 Year 2 Scoring (0-100 Points)

ge70 points Eligible for positive payment adjustment and exceptional performance bonus payment

1599 ndash 6999 points Positive payment adjustment No exceptional performance bonus payment No negative payment adjustment

15 points Neutral payment adjustment

376 ndash 1499 points Negative payment adjustment ranges from -49 percent to - 01percent

0 - 375 points -5 percent payment adjustment

Modified from CMS Quality Payment Program ndash Train-The-Trainer

Increase in performance threshold and payment adjustment

35

New Bonuses in 2018

Bonus eligibility Must report on at least one MIPS category

Bonus added to final MIPS Score

1 Complex Patient Bonus

Up to five bonus points for treating complex patients Score based on

bull Hierarchical Condition Category (HCC) risk score +

bull Percentage of dual eligible beneficiaries

2 Small Practice Bonus

Five bonus points added to final score of any MIPS eligible clinician or group in a small practice (15 or fewer clinicians)

Steps to Success in the Quality Payment Program

37

Steps to Success in the QPP

Determine Eligible Clinicians

Determine path

bull APM (group) or

bull MIPS (individual or group)

Collect data

bull Promoting Interoperability

bull Quality measures

bull Improvement activities

38

EIDM Account Set Up

To login and submit data clinicians will use their Enterprise Identity Management (EIDM) credentials

bull The EIDM account provides CMS customers with a single user identification they can use to access many CMS systems

bull The system will connect each user with their practice Taxpayer Identification Number (TIN) Once connected clinicians will be able to report data for the practice as a group or for individual clinicians within the practice

bull To learn about how to create an EIDM account see this user guide

bull Quick Start Guide

39

Clinicians Steps to Success in the QPP - continued

Review current performance

bull Foster performance improvement

bull Choose reporting periods for PI and IA

bull 90 ndash 365 days

bull Full calendar year for quality reporting

bull Evaluate available reporting methods

bull Choose group or individual performance

Contact QPP Resource Center for assistance

Steps to Success in the Quality Payment Program

37

Steps to Success in the QPP

Determine Eligible Clinicians

Determine path

bull APM (group) or

bull MIPS (individual or group)

Collect data

bull Promoting Interoperability

bull Quality measures

bull Improvement activities

38

EIDM Account Set Up

To login and submit data clinicians will use their Enterprise Identity Management (EIDM) credentials

bull The EIDM account provides CMS customers with a single user identification they can use to access many CMS systems

bull The system will connect each user with their practice Taxpayer Identification Number (TIN) Once connected clinicians will be able to report data for the practice as a group or for individual clinicians within the practice

bull To learn about how to create an EIDM account see this user guide

bull Quick Start Guide

39

Clinicians Steps to Success in the QPP - continued

Review current performance

bull Foster performance improvement

bull Choose reporting periods for PI and IA

bull 90 ndash 365 days

bull Full calendar year for quality reporting

bull Evaluate available reporting methods

bull Choose group or individual performance

Contact QPP Resource Center for assistance

38

EIDM Account Set Up

To login and submit data clinicians will use their Enterprise Identity Management (EIDM) credentials

bull The EIDM account provides CMS customers with a single user identification they can use to access many CMS systems

bull The system will connect each user with their practice Taxpayer Identification Number (TIN) Once connected clinicians will be able to report data for the practice as a group or for individual clinicians within the practice

bull To learn about how to create an EIDM account see this user guide

bull Quick Start Guide

39

Clinicians Steps to Success in the QPP - continued

Review current performance

bull Foster performance improvement

bull Choose reporting periods for PI and IA

bull 90 ndash 365 days

bull Full calendar year for quality reporting

bull Evaluate available reporting methods

bull Choose group or individual performance

Contact QPP Resource Center for assistance

Resources and Tools

41

Resources

1 QPP SURS Technical Assistance for Small practices (15 and under)

Stratis Health QIO QPPHelpstratishealthorg

MetaStar QIO qppmetastarcom

QPP Resource Center httpswwwqppresourcecentercom

2 Lake Superior Quality Innovation Network

Home page httpswwwlsqinorg

Previous and upcoming webinars and Regional Office Hours httpswwwlsqinorgevents

3 Stratis Health MIPS Estimator httpswwwmipsestimatororg

42

Estimated MIPS Score

Compare

reporting methods

Save view print and

download reports

Source Stratis Health MIPS Estimator

httpswwwmipsestimatororg

Promoting InteroperabilitySee how each

MIPS Category

contributes to

Score

Compare

individual and

group scores

43

QPP Support and Technical Assistance

CMS Website

wwwQPPCMSGov

CMS QPP Help Desk

866-288-8292

Email QPPcmshhsgov

Practice Transformation Networks (PTN)

CMS funded Transforming Clinical Practice Initiative (TCPI)

44

QUESTIONS

Lisa Gall DNP FNP LHIT-HP

QPPHelpstratishealthorg

Christopher Becker CPHIMS CPHIT

Mona Mathews PMP

qppmetastarcom