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MIPS Tips Webinar Series
MIPS Tips: Building a Foundation for Promoting Interoperability & Timely UpdatesMiranda Burzinski and Sharon PhelpsThursday, September 24, 20201 - 2 p.m. MT/noon - 1 p.m. PT/11 a.m. AK/9 a.m. HI
Supporting You Comagine Health, Mountain-Pacific Quality Health and the Network for Regional Healthcare Improvement are providing support to practices in Alaska, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington and Wyoming.
• Today’s slide deck can be found at a link in the chat.• Both the slide deck and recording will be made available a few days
following the event. Watch your email to be notified when they areavailable or visit https://bit.ly/2PagbeS to find all past MIPS Tips andQPP webinar recordings.
Topics• Category Basics• PI Requirements, Measures and Objectives• Exclusions, Exceptions, & Exemption• Links and Resources• Live Questions and Answers• Appendix A – QPP Navigation• Appendix B – Specification Example• Appendix C – 2021 Proposed Rule Updates
Promoting InteroperabilityCategory Basics
CMS Program Terminology
• Merit-based Incentive Payment System (MIPS)
• One of two components of the CMS Quality Payment Program. Performance ismeasured through the data clinicians report in four areas - Quality, ImprovementActivities, Promoting Interoperability, and Cost.
• Promoting Interoperability (PI)
• This category of the MIPS program promotes patient engagement and electronicexchange of information using certified electronic health record technology(CEHRT).
MIPS vs MIPS APM vs AAPM
• MIPS – weighting used by clinicians with an eligible clinician type• MIPS APM – weighting used by clinicians who:
• Are participating in an Alternative Payment Model (APM) which does NOT meetthe criteria to be an Advanced Alternative Payment Model (AAPM) or
• Are participating in an AAPM who do not meet Qualified Participant (QP) status.
• Advanced APM QPs – clinicians participating in an AAPM who meet QPstatus do NOT have to report MIPS.
NOTE: MIPS applies to Medicare Part B (not RHC/FQHC All Inclusive Rate nor
Medicare Advantage services)
2020 MIPS Performance Category Weights
90-Day Reporting Period
This is the LAST 90 days you can report for 2020!
MIPS PI Reporting
Promoting InteroperabilityPI Requirements, Measures and Objectives
• Requirements:
• Must be met to get a score• Do not contribute to the score
• Measures:
• Contribute to the score• Performance based or Yes/No
attestation
For information on where to find exact specifications for requirements and measures, see Appendix A.For a review of what data is contained in the specifications, see Appendix B
Requirements vs. Measures
Submission RequirementsFailure to meet = PI Category score of 0.
EHR Requirements for PI2015 Edition of CEHRT Required for Reporting
Functionality in place by first day of your 90-day reporting period
Must be certified by Office of the National Coordinator (ONC) to the 2015 Edition CEHRT criteria by last day of your performance period
Find your EHR’s 2015 Edition status from the Certified Health IT Product List (CHPL) at https://chpl.healthit.gov/#/search
Additional Requirements
• Prevention of Information Blocking• Ensure clinicians do not engage in activities that would knowingly or willfully
prevent or obstruct the electronic exchange of information (known as“information blocking”) within their certified electronic health record technology(CEHRT)
• ONC Direct Review Attestation• Clinicians must attest they are aware of the requirement to cooperate in good
faith with ONC direct review of their HIT if a request is received
Security Risk Analysis (SRA)Security Risk Analysis (SRA)
PI Objectives, Measures and Scoring
Points noted are maximum score based
on performance
on the measure.
Measure Reporting
• Each measure scored based on MIPS-eligible clinician’s performance for that measure (numerator/denominator or a “yes or no” statement)
• Measures with numerator/denominator, you must submit at least a 1 in the numerator if you do not claim an exclusion
• Failing to report on a required measure (or claim exclusion for a required measure, if applicable) will result in a score of zero for PI performance category
Scoring Methodology
E-Prescribing Objective• At least one prescription written by the MIPS eligible clinician
is queried for a drug formulary and transmitted electronically using CEHRT.
• NUMERATOR: The number of prescriptions in the denominator generated, queried for a drug formulary, and transmitted electronically using CEHRT.
• DENOMINATOR: Number of prescriptions written for drugs requiring a prescription in order to be dispensed other than controlled substances during the performance period; or number of prescriptions written for drugs requiring a prescription in order to be dispensed during the performance period.
• Exclusion allowed if:
• Fewer than 100 permissible prescriptions during the performance period
• Points reallocated to:• 5 points to Sending Health
Information measure and
• 5 points to Receiving Health Information measure
eRx Exclusion and Reallocation
e-Rx Steps to SuccessDetermine if you are using your EHR to e-prescribe.If NO, contact EHR vendor. Verify e-prescribing is available in your EHR and receive training on how to use it.
Can you run your MIPS dashboard?• If YES, check the e-prescription rates for Jan.
1, 2020, through current date or for the last 90 days.
• Verify you have eRX performance results
• Verify you have a numerator value of at least 1
• Does your data match what you expect to see?
• If NO, contact your EHR vendor to help get data for this measure.
Check your 2019 eRX denominator.If less than 100, study your 2020 rate to determine if you can take the exclusion.
Query of Prescription Drug Monitoring Program (PDMP) Measure
• BONUS measure – not required for PI
• Must submit e-prescribing measure to be eligible for optional measure / bonus points
• Must electronically prescribe opioids
• EHR must have Electronic Prescribing of Controlled Substances (EPCS) module
• Consists of 2 measures• PI_HIE_1: Support Electronic Referral Loops by Sending Health Information • PI_HIE_4: Support Electronic Referral Loops by Receiving and Incorporating Health
Information
• Refers to sending structured data fields electronically received directly into receiver’s EHR as structured field
• Fax is NOT considered an electronic transition
• Also referred to as “Transition of Care” measures• Movement of patient from one care setting to another
• Includes all transitions of care for clinician, not just referrals
Health Information Exchange Objective
Sending Health Information• For at least one transition of care or referral, the MIPS eligible
clinician (EC) that transitions or refers their patient to another setting of care or health care provider:
• (1) creates a summary of care record using CEHRT; and • (2) electronically exchanges the summary of care record.
• NUMERATOR: The number of transitions of care and referrals in the denominator where a summary of care record was created using CEHRT and exchanged electronically.
• DENOMINATOR: Number of transitions of care and referrals during the performance period for which the MIPS eligible clinician was the transferring or referring clinician.
• For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.
• NUMERATOR: The number of electronic summary of care records in the denominator for which clinical information reconciliation is completed using CEHRT for the following three clinical information sets: (1) Medication – Review of the patient's medication, including the name, dosage, frequency, and route of each medication; (2) Medication allergy – Review of the patient's known medication allergies; and (3) Current Problem List – Review of the patient’s current and active diagnoses.
• DENOMINATOR: Number of electronic summary of care records received using CEHRT for patient encounters during the performance period for which a MIPS EC was the receiving party of a transition of care or referral, and for patient encounters during the performance period in which the MIPS EC has never before encountered the patient.
Receiving Health Information
Receiving Health Information
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HIE Steps to Success
1. Review your MIPS dashboard to see your performance results for both measures.
1. If results present, ask your EHR vendor how to improve results
2. If results not present, ask your EHR vendor if set-up is completed and what workflow is needed to obtain results (High Priority!!)
2. Ask your EHR vendor if your CEHRT is sending to and receiving from your local hospital(s) and clinicians/clinics with whom you frequent refer.
3. Train your staff on workflow to send and receive referrals & transitions of care.
4. Know your Direct address to provide to your local hospital and clinicians/clinics with whom you frequently refer.
Direct Email
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Ask your EHR vendor what DIRECT address your CEHRT is using.
1. For at least one unique patient seen by the MIPS eligible clinician:1) The patient (or representative) is provided timely access to view online,
download, and transmit his or her health information; and 2) The MIPS EC ensures the patient's health information is available for the
patient (or 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 EC’s CEHRT.
2. There is NO exclusion for this measure.
Provider to Patient Exchange
Provide Patients Electronic Access Denominator and Numerator• Denominator
• Number of unique patients seen by clinician during performance period
• Patient seen more than once by provider but counted only once
• Numerator
• Timely access to view, download and transmit
• Access using application of choice (API)
If patient opts out, he/she is:–Included in the denominator and –Included in the numerator if provided information to access if/when desired
Provide Patients Access Steps to Success
• Verify settings and workflow with EHR vendor to send information for patient viewing, downloading, or transmitting.
• If possible, review how information appears for patients.• Provide patients information on how to access the portal• Provide patients with information on how they can use the data in the
portal
Public Health and Clinical Data Exchange Measures
• To earn maximum of 10 points, actively engage with TWO different Public Health Authorities or Clinical Data Registries
• Choose from the following five measures: • Immunization Registry Reporting • Syndromic Surveillance Reporting • Electronic Case Reporting • Public Health Registry Reporting • Clinical Data Registry Reporting
• If no “yes” responses and two exclusions are claimed, 10 points will be redistributed to ”Provide Patients Electronic Access to Their Health Information measure”
Public Health Reporting - YES
• The MIPS clinician is in Active Engagement with a Public Health Agency to submit data.
• Active Engagement Definition• Option 1 – Completed Registration to Submit Data• Option 2 – Testing and Validation• Option 3 – Submitting Production (patient care data)
Public Health Reporting - Exclusion
Each of the five measures has its own exclusions. • Refer to Measure Specifications Sheets for exact criteria for
each measure • Exclusions allowed under these circumstances:
• Does not diagnose or directly treat any disease or condition associated with a public health registry in the jurisdiction
• Operates in a jurisdiction for which no public health agency is capable of accepting electronic registry transactions (start of perf period)
• Operates in a jurisdiction where no public health registry for which the clinician is eligible has declared readiness to receive electronic transactions (6 months prior to perf period)
Public Health and Clinical Data Exchange• Must be actively engaged with two to earn maximum 10 points
• Exclusions are available if:If you… Then…Submit an exclusion for one measure, and submit “yes” for another measure
You can still earn the full 10 points for Public Health and Clinical Data Exchange objective
Claim two exclusions The 10 points will be redistributed to Provide Patients Electronic Access to Their Health Information measure under Provider to Patient Exchange objective
Are unable to report to two different public health agencies or clinical data registries and cannot claim an exclusion
You will earn a score of zero for the objective and PI performance category
Discussion Topics for Your EHR Vendor
Version of CEHRT
2015 Edition:- Functionality in place in your version
- Certification Status
Workflows to Meet Measures
- Direct email address(es)
Public Health and Clinical Data registry connections
Promoting InteroperabilityExclusion, Exceptions, and Exemptions
Exclusion, Exception and Exemption
Hardship Exceptions
• Submit the PI Hardship Exception application no later than 12/31/2020.
• Application is in QPP Portal
• HARP Account Required
• If approved, PI category will be reweighted to the Quality category
• Save documentation of the exception acceptance
Extreme and Uncontrollable Circumstances (EUC) Exception/Exemption Application Data
• Submit the EUC Exception application no later than 12/31/2020.
• Application is in QPP Portal
• HARP Account Required
• Can be applied for at the group or individual level
• Can apply for one to all four MIPS categories
• Save documentation of approval for audit records
How do I decide to take an exclusion, exception, exemption or submit data?
Do you have data for each measure?
- If no, consider exception
What is your score in the PI category? How does that compare to reweighting to Quality?
Using and monitoring the PI category means you are using data from others – lower cost and better efficiency
What’s the future hold? Is this an opportunity to learn how to do eRX, are your patients interested in accessing their data online, are you doing many referrals?
Promoting InteroperabilityLinks and Resources
• 2020 Promoting Interoperability Quick Start Guide (PDF)
• Subscribe to updates on QPP at the bottom of the page: https://qpp.cms.gov/
CMS PI Quick Start Guide and QPP Subscribe
QPP Resources: Promoting InteroperabilityThe QPP Resource Library Fact sheets, measure specifications, specialty guides, technical guides, user guides, helpful videos and more
2020 MIPS Quick Start Guide High-level overview of MIPS requirements to get you started with participating in 2020 performance period
2020 MIPS Eligibility and Participation Quick Start Guide
High-level overview and actionable steps to understand your 2020 MIPS eligibility and participation requirements
2020 Promoting Interoperability Measure Specifications Detailed overview of requirements for 2020 PI performance category objectives and measures
2020 Promoting Interoperability Performance Category Quick Start Guide
Focuses on PI performance category; provides high-level requirements about data collection and submission for 2020 performance period (does not review requirements for MIPS APM participants scored under APM Scoring Standard)
Certified Health IT Product List (CHPL) User Guide Instructions for generating required CMS EHR Certification ID (https://chpl.healthit.gov/#/search)
2020 Quality Payment Program (QPP) Exception Applications Fact Sheet
Addresses automatic extreme and uncontrollable circumstances policy as it applies to MIPS-eligible clinicians affected by natural disasters or COVID-19 during performance year 2020 and the PI hardship exception policy
2020 Quality Payment Program Final Rule FAQs MIPS frequently asked questions for 2020 QPP
QPP Participation Status Lookup Tool QPP webpage to look up participation status using clinician NPI number
Eligibility Determination Periods and Snapshots QPP webpage explaining Eligibility Determination Period and Snapshots with APMs noted separately
Acronym ListIA: Improvement Activities
ACO: Accountable Care Organization
AAPM: Advanced Alternative Payment Model
APM: Alternative Payment Model
CEHRT: Certified Electronic Health Record Technology
CHPL: Certified Health IT Product List
CMS: Centers for Medicare & Medicaid Services
EC: Eligible Clinician
EP: Eligible Professional
FQHC: Federally Qualified Health Center
HARP: HCQIS Access Roles and Profiles
MACRA: Medicare Access and CHIP Reauthorization Act of 2015
MSSP: Medicare Shared Savings Program
MU: Meaningful Use (EHR Incentive Program)
NPI: National Provider Identifier
PDMP: Prescription Drug Monitoring Program
PI: Promoting Interoperability
QCDR: Qualified Clinical Data Registry
QIO: Quality Improvement Organization
QP: Qualified Participant
QPP: Quality Payment Program
RHC: Rural Health Clinic
TIN: Taxpayer Identification Number
How to Ask a Question
Please Fill Out Our Evaluation
• An evaluation link for this session is currently being place in the chat. Please take a few minutes before you leave the meeting today to fill out an evaluation and help us improve our offerings.
Contact a QPP Expert in Your State!
State Contact Info
Idaho London [email protected]
Nevada Aaron [email protected]
Oregon Seema [email protected]
Utah Perrin [email protected]
Washington Jeff [email protected]
State Contact Info
Alaska, Hawaii, Wyoming and Territories
Miranda Burzinski907-561-3202, ext. [email protected]
Montana Alison [email protected]
Region/Senior Account Manager
Sharon [email protected]
Comagine Health Email: [email protected]: https://bit.ly/2snFVeL
Mountain-Pacific Quality HealthEmail: [email protected]: https://bit.ly/2FFY1zO
Appendix A- QPP Navigation
Access to PI Measures
Download the PDF measure specifications.
https://qpp.cms.gov/mips/promoting-interoperability
Content of Individual Measure Specification
Sheets• Measure Information
– Objective, measure, measure ID• Definition of Terms• Reporting Requirements
– Numerator/Denominator• Scoring Information• Additional Information• Regulatory References• Certification Criteria and Standards
These are an excellent reference.
Appendix B – Measure Specification Example
E-Prescribing Objective and Measure (1 of 6)
These are QPP data fields
Screenshots from Centers for Medicare & Medicaid Services (CMS) PI E-Prescribing Measure Specification
Reporting Requirements and Scoring (2 of 6)
These requirements are the same
for each objective.
Additional Information (3 of 6)
Unique to the objective/measure
Additional Information Summary (4 of 6)
• Types of items included or excluded from num/den
• What constitutes electronic submission
• Controlled substances where feasible and allowable
• Fax and OTC medications not included
• Include transmissions internal and external to organization
Unique to the objective/measure
Additional Information
Summary (5 of 6)
• ONC Certification Standards for Electronic Prescribing
• E-prescribing fulfills a statutory requirement
• Clinician can limit effort to query a formulary to within function of CEHRT
Unique to the objective/measure
Regulatory References and Certification Criteria (6 of 6)
2021 Proposed Rule Highlights
• MIPS Value Pathways (MVPs) – delayed until 2022 due to COVID-19• New APM Performance Pathway (APP) to replace MIPS APM
• Aligns with MVP framework• Allows MSSP ACOs to dual report for ACO and APP with single submission• Streamlines quality measures to 6 measures• CMS Web Interface removed as reporting option
• MIPS Quality category – use performance year benchmark rather than historical benchmark due to COVID-19 impact on 2019 measure results.
• Changes to determining topped out measures• Changes to 112 measures; 14 measures removed; 206 MIPS measures total• Specialty set changes
Other MIPS Category highlights
• Improvement Activities – activity changes• 2 modified
• Cost - No new cost measures• Total Per Capita Charges (TPCC) - revised• Medicare Spend Per Beneficiary (MSPB) - unchanged• 18 Episode measures - unchanged• Telehealth incorporated as appropriate in TPCC and Episode measures
• Promoting Interoperability:• PDMP Bonus to 10 points• Optional HIE bidirectional exchange measure in lieu of Sending and Receiving Health
Information measures
By the numbers…
• Neutral benchmark – 50 points
• Exceptional Performance Threshold - 85 points
• Complex Patient Bonus (For 2020 only) – 10 points
2021 Proposed Category Weights
Changes in GREEN
Misc changes
• Scoring flexibilities• Third party intermediates• Qualified Clinical Data Registry requirements
• For an in-depth review, see the 2020 Proposed Rule fact sheet on the Resources web page: https://qpp.cms.gov/about/resource-library
• Comments for the proposed rule are due October 5, 2020