Most quality measures can be used for 90-day performance period. There are some measures, though, that by design, are hard to align with a 90-day performance period and some are not feasible for certain timeframes in which the measure may be analyzed.
For example, some measures are based on observation periods after an event such as a surgery or discharge from acute care. MIPS Quality ID: 191, CMS133: Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery, has a 90-day look forward period of observation after the denominator qualifying event of cataract surgery. This is accommodated in the measure specification by including only cataract surgeries in the first 270 days of the year (January 1 through September 30) allowing for follow-up assessment within 90- days post-surgery (October 1 through December 31) before the end of the calendar year. Therefore, a 90-day performance period that included dates in October, November, or December would not be feasible for submission purposes and an alternative to the 4th quarter 90-day submission period should be selected for this measure.
There are 43 quality measures that may not be ideal if implemented within the 90-day performance period; the limitations and rationale associated with these measures are indicated in the table, located in the appendix of this CMS document.
MIPS Data Validation and Auditing
The Quality Payment Program Final Rule with comment requires CMS to provide the criteria it will use to audit and validate measures and activities for the 2017 transition year of MIPS for the Quality, Advancing Care Information, and Improvement Activities performance categories.
By definition, data validation is the process of ensuring that a program operates on accurate and useful data. MIPS requires all-payer data for all data submission mechanisms with the exception of claims and the CMS Web Interface. The data from payers other than Medicare will be used for informational purposes to improve future validation efforts and will not be the only source of data used to make final determinations on whether you pass or fail an audit from the 2017 transition year.
Under MIPS, CMS will conduct an annual data validation and audit process.
How long should I retain documentation?
In accordance with the False Claims Act, you should keep documentation up to 6 years and, as finalized in the 2018 MIPS Year 2 final rule, CMS may request any records or data retained for the purposes of MIPS for up to 6 years.
The Quality performance category within MIPS assesses health process and outcomes through quality measures.
MIPS eligible clinicians should demonstrate quality performance assessed against a performance benchmark. The performance benchmark is based on historical or performance period data (or potentially based on 2017 performance data for quality measures with no historic benchmark).
For the 2017 transition year, CMS’ data validation process for the Quality performance category will apply for claims, EHR, and registry submissions to validate whether you submitted all applicable measures and encounters when submitting fewer than six measures or when you do not submit the required outcome measure or other high priority measure, or submit less than the full set of measures in the applicable specialty set.
Advancing Care Information
The MIPS Advancing Care Information performance category replaces the Medicare EHR Incentive Program for eligible professionals, also known as Meaningful Use. The MIPS Advancing Care Information performance category promotes patient engagement and the electronic exchange of information using certified EHR technology. Under this performance category, eligible clinicians will have greater flexibility in choosing measures to report.
You should retain documentation to support submissions for the Advancing Care Information performance category.
The MIPS Improvement Activities performance category assesses how much you participate in activities that make clinical practice better. Examples include:
Under this performance category, you’ll be able to choose from many activities to show your performance. This performance category also includes incentives to help you participate in certified patient-centered medical homes and APMs.
Your documentation used to validate your activities should demonstrate consistent and meaningful engagement within the period for which you attested.
The following CMS document describes Track 1 Accountable Care Organization (ACO) status for the MIPS performance categories and the MIPS APM scoring standard:
To prevent actions that block the exchange of health information, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the Quality Payment Program final rule with comment period require MIPS eligible clinicians to show that they have not knowingly and willfully limited or restricted the compatibility or interoperability of their certified electronic health record (EHR) technology. MIPS eligible clinicians show that they are meeting this requirement by attesting to three statements about how they implement and use certified EHR technology (CEHRT). Together, these three statements are referred to as the “Prevention of Information Blocking Attestation.”
Do I Have to Attest?
If you are a MIPS eligible clinician who reports on the advancing care information performance category you must attest to the prevention of information blocking attestation. If you are reporting as a group, the prevention of information blocking attestation by the group applies to all MIPS eligible clinicians within the group. Therefore, if one MIPS eligible clinician in the group fails to meet the requirements of the Prevention of Information Blocking Attestation, then the whole group would fail to meet the requirement.
What Actions Are Required?
If you want to earn a score for the advancing care information performance category, you have to act in good faith when you implement and use your CEHRT to exchange electronic health information. This includes working with technology developers and others who build CEHRT to make sure the technology is used correctly and is connected (and enabled) to meet applicable standards and laws. You must also ensure that your organizational policies and workflows are enabled and do not restrict the CEHRT’s functionality in any way. For example, if your CEHRT gives patients access to their electronic health information or exchanges information with other MIPS eligible clinicians, your practice must use these capabilities.
Statements to Which I Am Attesting
Do I Have to Show Any Documentation to Attest?
You do not have to give us any documentation to show you have acted in good faith to:
Where Can I Learn More?
Improvement Activities Eligible for ACI Bonus Score:
You can find further information here.
One can find here suggested documentiation to keep regarding specific Improvement Activities. Other general suggestions:
For quality measures, CMS used data that was reported via PQRS 2015 to create performance benchmarks.
Each quality measure is converted into a 10 point scoring system. Performance on quality measures is broken down into 10 "deciles", with each decile havinga value of between 1 and 10 points. A clinician or group's performance on a quality measure will be compared to the performance levels in the national deciles. Registry measures are compared to registry benchmarks.
A measure can be reliably scored against a benchmark if...
A national benchmark exists (i.e. for some measures there is no data from the 2015 PQRS period)
The sufficient case volume has been met (more than 20 cases)
At least 50% of possible data for a measure is submitted (data completeness)
Note: If a measure cannot be scored against a benchmark or no benchmark exists, it will automatically receive 3 points as long as it is complete.
Eligibile clinicians submitting via claims or a qualified registry who submit less than 6 measures or no outcome or high priority measure will be subject to EMA (Eligibility Measure Applicability) process to determine if additional clinically related measures could have been submitted. If CMS determines that there are no applicable measures for the clinician, they won't be held accountable for not submitting those measures. If CMS discovers that additional clinically related measures could have been submitted and were not, it will impact the Quality performance category final score.
An enhanced version of MAV (Measure Applicability Validation)
Adjusts performance in the quality performance category when appropriate
Based on evaluation of submitted measures and determination of clinically related measures aligned with specialty measures sets
Specific to the submission mechanism. For example, EMA will not determine that a registry submitter had a claims measure available.
Not applicable to EHR, QCDR and Web interface data submission mechanisms
Process Measures - Process measures show what doctors and other clinicians do to maintain or improve health, either for healthy people or those diagnosed with a given condition or disease. These measures usually reflect generally accepted recommendations for clinical practice. Process measures can tell consumers about medical care they should receive for a given condition or disease, and can help improve health outcomes.
Outcome Measures - Outcome measures show how a health care service or intervention influences the health status of patients. Examples: The % of patients who died becauses of surgery or the rate of surgical complications or hospital acquired infections. Outcome measures are the result of many factors, some of which may be out of a clinician's control.
High priority Measures - High priority measures include the following categories of measures: Outcome, Appropriate Use, Patient Experience, Patient Safety, Efficiency measures, Care coordination.
Quality Performance Category: Your ACO is required by the Shared Savings Program to report quality measures through the CMS Web Interface. The quality data reported to the CMS Web Interface by the ACO will be used to score the MIPS Quality performance category and the score will apply to each MIPS clinician in the ACO.
Improvement Activities and Cost Categories: As a MIPS clinician in the Shared Savings Program ACO you won’t need to report any data for the MIPS Improvement Activities performance category because you will automatically receive full points for this category. In addition, MIPS clinicians in a Shared Savings Program ACO will not be assessed on the MIPS Cost performance category.
Advancing Care Information Category: All ACO participant TINs in a Shared Savings Program ACO, including ACO participant TINs that are in a Track 2 or 3 ACO, are responsible for submitting data on the Advancing Care Information performance category apart from the ACO as specified by MIPS. This information is necessary for the Shared Savings Program to measure the level of CEHRT use among clinicians participating in the ACO.
APM Scoring Standard: The Shared Savings Program is a MIPS APM, and all MIPS clinicians in Shared Savings Program ACOs will receive special scoring for MIPS under the APM scoring standard. Consequently, all MIPS clinicians in your ACO will receive the same MIPS final score.
What if my ACO does not successfully report quality measures through the CMS Web Interface? While unlikely, since most ACOs successfully report quality measures through the CMS Web Interface, if you believe your ACO won’t report what it needs to under the Shared Savings Program, your ACO 4 Quality Payment Program Fact Sheet participant TIN can submit quality data for the performance year under any of the MIPS standard reporting options. If the ACO doesn’t meet its reporting requirements, we’ll look for and use any quality data for the performance year that your ACO participant TIN sent in apart from the ACO to score your quality domain under MIPS. Your ACO participant TIN will still receive full points for the MIPS Improvement Activity performance category and it will not be assessed on the MIPS Cost performance category. Your ACO participant TIN will still need to report for the Advancing Care Information category according to the MIPS requirements for this category. Instead of being scored at the ACO level, the MIPS clinicians under each ACO participant TIN will receive their own MIPS final score.
For More Information:
Oct. 2 is the deadline for providers to start tracking data under MIPS. Missing that deadline could result in a financial penalty in 2019. Providers electing to report partially for a 90 day period who have not been tracking data all year, must start by 10/2 in order to accomplish the full 90 day reporting period.
Certified electronic health record technology (CEHRT) is required for participation in the advancing care information performance category of the Quality Payment Program (QPP). Under Merit-based Incentive Payment System (MIPS) scoring, MIPS-eligible clinicians and groups may qualify for a reweighting of their advancing care information performance category score to 0 percent of the final score if they meet the criteria outlined below. The 25 percent weighting of the advancing care information performance category would be reallocated to the quality performance category. Simply lacking CEHRT does not qualify the MIPS-eligible clinician or group for reweighting. MIPS-eligible clinicians and groups that are participating in a MIPS Alternative Payment Model may be exempted from reporting information for the advancing care information performance category if they meet the criteria outlined below:
A MIPS-eligible clinician or group may submit a Quality Payment Program Hardship Exception Application, citing one of the following specified reasons for review and approval:
There are some MIPS-eligible clinicians that are considered Special Status, who will be automatically reweighted (or exempted in the case of MIPS-eligible clinicians participating in a MIPS APM) and do not need to submit a Quality Payment Program Hardship Exception Application.
For 2017, Special Status clinicians include the following:
A group’s advancing care information performance category score is automatically reweighted, (or exempted in the case of groups participating in a MIPS Alternative Payment Model (APM)), and the group would not need to submit a Quality Payment Program Advancing Care Information Hardship Exception Application if all of their MIPS-eligible clinicians within the group receive a hardship exception or fall into one or more of the Special Status categories above, with the exception of a non-patient facing group which only requires that 75 percent of clinicians are non-patient facing.
In addition, a group is automatically reweighted (or exempted) and does not need to submit a Quality Payment Program Hardship Exception Application if it is non-patient facing. Groups are considered non-patient facing if more than 75 percent of its clinicians have 100 or fewer patient-facing encounters (including Medicare telehealth services).
If all of the MIPS-eligible clinicians within a group do not qualify for an automatic reweighting or do not submit an application for and receive a hardship exception, the group will not qualify for an automatic reweighting and will have to report on the advancing care information performance category.
Improvement Activities are sorted into the following subcategories. Note that when using the MIPS Measures Planning and MIPS Measures Reporting tools within the MDinteractive software, you can filter the list of IA's by sub-category:
1. Achieving Health Equity: Engagement of new Medicaid patients and follow-up.
2. Behavioral and Mental Health: Activities that look at the co-morbidity of mental health and physical health. Some cross-over with Quality measures.
3. Beneficiary Engagement: Engagement of patients through post-visit surveys, tracking reported outcomes, using care plans to manage chronic conditions.
4. Care Coordination: Coordination of care between clinicians. Health information exchange, coordinated planning, etc.
5. Emergency Response & Preparedness: Supporting communities by registering to be part of a disaster relief team or participation in supporting humanitarian needs.
6. Expanded Practice Access: How accessible you are to your beneficiaries?
7. Patient Safety and Practice Assessment Population Management: Patient safety monitoring programs (i.e. prescriptions drug monitoring, appropriate use of antibiotics, etc.
8. Population Management: Population health. Using research, tools, etc.
Note: Many of the medical society sites have posted suggestions for their specialties for the IA category.
Clinicians practicing in RHCs or FQHCs who provide services that are billed exclusively under the RHC or FQHC payment methodologies are not required to participate in MIPS (they may voluntarily report on measures and activities under MIPS) and are not subject to a payment adjustment.
However, if these clinicians provide other services and bill for those services under the Physician Fee Schedule (PFS), they would be required to participate in MIPS and such other services would be subject to a payment adjustment.
Clinicians included in MIPS and practicing in CAHs are required to participate in MIPS unless they are exempt.
For MIPS clinicians practicing in Method I CAHs, the MIPS payment adjustment would apply to payments made for items and services that are Medicare Part B allowed charges billed by the MIPS clinicians. The payment adjustment would not apply to the facility payment to the CAH itself.
For MIPS clinicians practicing in Method II CAHs who have assigned their billing rights to the CAH, CMS would apply the MIPS payment adjustment to the Method II CAH payments. For MIPS clinicians practicing in Method II CAHs that have not assigned their billing rights to the CAH, the MIPS payment adjustment would apply in the same way as for MIPS clinicians who bill for items and services in Method I CAHs.
All MIPS clinicians will report data for the Advancing Care Information performance category as usual according to the general MIPS requirements. MIPS clinicians can report their Advancing Care Information data via attestation and the CMS Web Interface (only available for groups of 25 or more), which you can access via qpp.cms.gov, as well as through a QCDR, Qualified Registry like MDinteractive, or Certified EHR technology (CEHRT).
All Medicare Shared Savings Program ACO participant Tax Identification Number’s (TINs) must report the MIPS Advancing Care Information performance category regardless of whether they meet the QP thresholds or not. The Medicare Shared Savings Program ACO participant TIN scores for this performance category will becombined as a weighted average based on how many MIPS clinicians are in each TIN. This will result in one ACO group score for the Advancing Care Information performance category that applies to all MIPS clinicians in the ACO.
For the Next Generation ACO model and all other MIPS APMs under the APM scoring standard, MIPS clinicians in the APM report on the Advancing Care Information performance category through either a group TIN or individual reporting. We’ll score each MIPS clinician in the APM using the highest score for the TIN/NPI combination for each MIPS clinician, which may be from individual or group reporting. The score given to each MIPS clinician will be averaged with the scores of the other clinicians in the APM Entity group to produce one APM entity score for the Advancing Care Information performance category.
The Advancing Care Information performance category for the 2017 performance period is weighted at 30 percent for the Medicare Shared Savings Program and the Next Generation ACO model MIPS APMs. For all other MIPS APMs this performance category is weighted at 75 percent for the 2017 performance period.
For further info please see:
MIPS APM Fact Sheet: Provides an overview of a specific type of APM, called a "MIPS APM," and the special APM scoring standard used for those in MIPS APMs.
CMS estimates that approximately 676,722 eligible clinicians would be required to participate in MIPS in the 2017 MIPS performance period. Under the proposed rule, the payment adjustment for the 2019 payment year would range from - 4% to +4X% where X is an adjustment factor to allow the MIPS program to stay budget neutral.
According to CMS, MIPS eligible clinicians would receive approximately $199 million in positive MIPS payment adjustments, including up to an additional $500 million for those with exceptional performance (eligible clinicians whose final score is 70 points or higher). CMS also estimates that 5.3% of the providers eligible for MIPS in 2017 will get a penalty. The average MIPS payment amount would be 0.94%.
CMS estimates these numbers based on projecting past PQRS participation, past PQRS performance scores and past EHR Meaningful Use participation into the 2017 MIPS rules.
Based on the CMS numbers, the penalty for not reporting MIPS for a clinician with an average of $116,000.00 in Medicare Part B income, will be $4,640 (4% negative payment adjustment).
We estimate that the average payment for a clinician with a MIPS score between 3 and 100 will be $1,090 (0.94% positive payment adjustment). As shown in the graph above, the largest payments will apply to clinicians with MIP scores above 70.
The reward for a perfect MIPS score of 100 points could be around 2.4% percent ($3,400 for a clinician with an average $116,000 of Medicare income).
For Registry, EHR, and QCDR one must have a minimum of one eligible Medicare Part B Patient (regardless of how many Measures you Report) in order to utilize that Reporting Option. There should be one Medicare patient in the denominator of at least one measure (out of the required six). The Medicare patient does not have to be in the numerator. To further clarify, one will need a Medicare patient in the population that qualifies for the measure, but one do not necessarily need to report on that patient.
Example: If one report 8 measures via EHR, Registry, or QCDR -- one only need "1" eligible Medicare patient total in order to meet the minimum requirements for the 2017 MIPS Program.
The Data completeness criteria for a quality performance category is that one needs to report at least 50 percent of the MIPS eligible clinician or group's patients that meet the measure's denominator criteria, regardless of payer.
An additional Outcome measure (beyond the one required) is worth 2 bonus points. Measure #321 (CAHPS for MIPS survey) as an additional measure is also worth 2 bonus points because it is a patient experience measure. Any additional high priority measure that doesn't also fall into one of those two categories mentioned would be worth 1 bonus point. Everything mentioned in this paragraph regarding "additional" measures is subject to the cap of 10% of the total possible points for the Quality performance category.
For the Quality category, to get bonus points for "additional" Outcome, patient experience (CAHPS for MIPS), or high priority measures, the measure does not have to fall into the top six/best six that are scored and used for the Quality performance category score, but to be eligible for "additional measure" bonus points, the measure must meet the 50% Data Completeness requirement (Reporting Rate), and meet the 20 case minimum volume threshold submitted, AND have a performance rate above 0 percent.
Also, a Quality measure collected via end-to-end certified EHR technology (CEHRT) would also yield 1 bonus point for the Quality category, subject to the cap of 10% of the total possible points for the category.
This means that overall, you can get up to 20% in bonus points in the Quality performance category from the two bonus categories above.
CMS defines a patient-facing encounter as an instance in which a MIPS eligible clinician billed for services such as general office visits, outpatient visits, and procedure codes under the Medicare Physician Fee Schedule.
What is the Patient-facing Encounters Codes List?
This list of patient-facing encounter codes is used to determine the non-patient facing status of MIPS eligible clinicians. A non-patient facing MIPS eligible clinician is:
The list of patient-facing encounter codes are categorized into three overarching groups of codes:
The utilization of Evaluation and Management Codes, Surgical and Procedural Codes, and Visit Codes accurately classifies MIPS eligible clinicians as non-patient facing and patient-facing.
Given the flexibility in program requirements for non-patient facing clinicians, the encounter codes are critical for CMS to identify MIPS eligible clinicians.
There are a lot of questions from providers about where CMS says one must report both Medicare and non-Medicare patient data. The requirement can be found under the Data Completeness requirements in the final rule. Here are some citations:
§ 414.1340 Data completeness criteria for the quality performance category (page 77542 of Federal Register Notice, Friday, November 4, 2016):
(a) MIPS eligible clinicians and groups submitting quality measures data using the QCDR, qualified registry, or EHR submission mechanism must submit data on:
(1) At least 50 percent of the MIPS eligible clinician or group’s patients that meet the measure’s denominator criteria, regardless of payer for MIPS payment year 2019.
(2) At least 60 percent of the MIPS eligible clinician or group’s patients that meet the measure’s denominator criteria, regardless of payer for MIPS payment year 2020.
CMS also noted the following response in the final rule regarding data completeness on page 77123 of the Federal Register Notice:
Response: We can appreciate the concerns raised by the commenter. We are continuing to use a 50 percent data completeness threshold similar to what was used under PQRS. We do note however that under MIPS the data completeness threshold applies for both Medicare and non-Medicare patients.
We are finalizing our approach of including all-payer data for the QCDR, qualified registry, and EHR submission mechanisms because we believe this approach provides a more complete picture of each MIPS eligible clinician’s scope of practice and provides more access to data about specialties and subspecialties not currently captured in PQRS.
The reporting rate is the percentage of times that you answered all of the questions related to a particular measure. For individual measures, your reporting rates must be at least 50% meaning you answered the quality questions on 50% or greater of the patient records created and who were available for the measure.
The performance rate is the percentage of times you met the measure (answered "done" or "performed") compared to the number of eligible patients entered for the measure.
Performance rates of 100% are a perfect score. There are measures (i.e. Measure 1 Hemoglobin A1c) where a lower calculated performance rate is better. These are called inverse measures and a performance rate of 0% would be a perfect score.
Start by reviewing the suggestions by specialty available on our website: http://www.mdinteractive.com/2017_MIPS_by_Specialty
The measures you select should reflect your patient population, specialty and practice.
You can also access our MIPS planning tool within our software by logging into your account and selecting from the drop down menu: MIPS Measures Plans. This interactive tool will allow you to search for Quality measures by specialty, determine which measures are outcome or high priority and also view the earning potential based on performance for each measure.
This planning tool will also allow you to select measures for the ACI and CPIA components for planning purposes.
If you look at your claim forms you will see that there are two different spots for NPIs. The 33a field is where the Group NPI is listed. Please do not report MIPS using the Group NPI.
The 24J field should contain the individual NPI. The TIN in field 25 and the individual NPI listed in 24J should always be used to report MIPS.
For the Quality component of MIPS, each individual measure is reported on at least 50% of the provider or groups Medicare and non-Medicare patients.
When reporting an individual measure, a provider must report on at least 50% of all Medicare and non-Medicare patients who meet the eligibility of that measure. For MIPS Quality scoring however, only measures with at least 20 patients/records in the denominator will be scored (compared against national benchmarks) for possible additional points.
Yes. Each Quality measure is reported on at least 50% of all eligible cases - Medicare and non-Medicare - across a minimum of 90 consecutive days. Measures that are reported with less than 20 cases will earn 3 points and will not be scored against national benchmarks.
Yes. CMS will make their payment adjustment based on the most complete set of data received. The two methods cannot be combined however.
MIPS reporting of individual measures applies to all patients. Eligibility for a measure is based on CMS documentation (denominator criteria).
A practice can report as individuals or as a group via MDinteractive.
Group reporting is available to practices of 2 or more providers operating under a single TIN. If at least one provider in the group has eligible patient visits to report, every member of the group will avoid the MIPS penalty. There is no CMS registration for group reporting in 2017. We ask that you contact us via e-mail (email@example.com) if you will be submitting as a group.
Measures Group reporting has been removed as an option beginning in 2017. All providers/groups must report individual measures only.
The CAHPS for MIPS survey is optional for all groups of 2 or more eligible clinicians, but MIPS provides several incentives for groups to participate.
Quality - 60% of total score - 60 points max for most providers.
Each measure 1-10 points compared to historical benchmark (if avail.)
Bonus for reporting additional outcomes and high priority measures
Performance plus bonus points are added and divided by 10x the number of scored measures (maximum = 60 points for most providers).
Advancing care information - 25% of total score - 25 points maximum
Base score of 50% - 12.5 points is achieved by reporting at least one use case for each available base measure. Base measures total either 4 or 5 depending on the edition of EHR (2014 or 2015). Base score measures must be completed in order to earn performance or bonus points.
Up to 10 additional performance points available per performance measure (90%) or 22.5 points max
Up to 15% - 3.75 points for bonus measures
Note: Points max out at 100 (even though there is the potential to earn more). 100+ = 25 points max.
CPIA - 15% of total score or 15 points max.
Each activity worth 10 points (medium weight); double weight (20 points) for “high” value activities
Activities are worth double for small practices, etc.
Reporting 40 points worth of measures (i.e. 4 medium weighted activities or 2 high weighted) to earn 15 points for CPIA.
Years 1 and 2: Physicians*, PAs, NPs, Clinical nurse specialists, Certified registered nurse anesthetists
*Physician means doctor of medicine, doctor of osteopathy (including osteopathic practitioner), doctor of dental surgery, doctor of dental medicine, doctor of podiatric medicine, or doctor of optometry, and, with respect to certain specified treatment, a doctor of chiropractic legally authorized to practice by a State in which he/she performs this function.
Years 3+ : Physical or occupational therapists, Speech-language pathologists, Audiologists, Nurse midwives, Clinical social workers, Clinical psychologists, Dietitians /
MIPS reporting options for this transition year are:
Test the program - avoid an automatic -4% adjustment in 2019 by reporting 1 Quality Measure or 1 Improvement Activity or the ACI base measures. Earning a minimum of 3 points will allow a provider/group to avoid a penalty. Submitting 1 Quality measure (for example) will earn 3 points.
90 Day Reporting Option - Earn an positive payment adjustment by reporting all 3 components of MIPS - Quality (6 measures including at least 1 Outcome or High-Priority measure), ACI (base measures plus performance) and CPIA for a 90 day period beginning sometime between January 1 and October 1, 2017.
Full Year Reporting Option - Same as 90 days but for a full year. This option is what will become the full program requirements beginning with the 2018 reporting period.
The following categories of providers are excluded from MIPS reporting:
Newly-enrolled in Medicare:
Enrolled in Medicare for the first time during the performance period (exempt until following performance year)
Below the low-volume threshold:
Medicare Part B allowed charges less than or equal to $30,000 a year
See 100 or fewer Medicare Part B patients a year
Significantly participating in Advanced APMs:
Receive 25% of your Medicare payments
See 20% of your Medicare patients through an Advanced APM
The deadline for submitting data into our registry for 2017 MIPS reporting is March 2, 2018.
Please note that the 2016 reporting period is closed.
The reporting period for 2017 MIPS is the calendar year.
In the transition year, which is 2017, providers are able to "pick their pace". There are 4 options: not reporting which would result in an automatic 4% penalty, the test pace where a provider submits some data, a 90 day reporting period or a full calendar year.
The 90 day reporting period can be any continuous 90 day period in 2017. You will not be able to collect data using this option after October 1.
The CMS portal to send MIPS data opens in January 2018. We will begin sending complete data that has been reviewed by our team beginning in January 2018 and continue through March 2018.
All data submitted to MDinteractive for 2016 was sent to CMS by March 31, 2017.
Yes. Our site has been updated for 2017 and you may begin creating patient records in the software. If you do not see a particular measure in your drop-down menu, please contact us via our 800# (1-800-634-4731), e-mail (firstname.lastname@example.org) or chat on our website.
You can begin entering data from the beginning of the year to the present and then continue to add patients until December 31, 2017. For individual measures, it is suggested that you start entering the data as early in the year as possible.
All data must be submitted to MDinteractive by February 15, 2018.
Non-patient facing MIPS eligible clinicians will have their ACI category automatically reweighted to zero by CMS.
"We proposed to automatically reweight the advancing care information performance category to zero for a MIPS eligible clinician who is classified as a non-patient facing MIPS eligible clinician (based on the number of patient-facing encounters billed during a performance period) without requiring an application to be submitted by the MIPS eligible clinician."
"Under the MIPS, we proposed to automatically reweight the advancing care information performance category to zero for any hospital-based MIPS eligible clinicians and/or nonpatient facing MIPS eligible clinicians who may not have sufficient measures applicable and available to them."
Hospital-based MIPS eligible clinicians will have the ACI category automatically weighted to zero by CMS. Hospital-based ECs are those who provide 75 percent or more covered professional services in the inpatient hospital (POS 21), on campus outpatient hospital (POS 22) or emergency room (POS 23) settings.
"For these reasons, we proposed to rely on section 1848(q)(5)(F) of the Act to assign a weight of zero to the advancing care information performance category for hospital-based MIPS eligible clinicians."
"With consideration of the comments and data we have reviewed, we are reducing the percentage of covered professional services furnished in certain sites of service to determine hospital-based MIPS eligible clinicians from 90 percent to 75 percent. The data analyzed supports the comments we received while still allowing MIPS eligible clinicians with 25 percent or more of their services in a settings outside of inpatient hospital, on-campus outpatient hospital (as referenced below) or emergency room settings to participate and earn points in the advancing care information performance category."
"We agree with commenters that there are MIPS eligible clinicians who bill using place of service codes other than POS 21 and POS 23 but who predominantly furnish covered professional services in a hospital setting and have no control over EHR technology. We believe these clinicians should be considered hospital-based for purposes of MIPS, and therefore, we are expanding our hospital-based definition to include POS 22, on-campus outpatient hospital."
"Comment: Some commenters requested that CMS clarify the proposal to eliminate the need to track and report duplicative quality measures by modifying its proposal to require that if quality is reported in a manner acceptable under MIPS or an APM, it would not need to be reported under the Medicaid EHR Incentive Program. The commenters were concerned the programs could potentially cause the same conflict CMS specifically noted MIPS and APMs were intended to correct.
CMS Response: We thank the commenters and have worked to eliminate duplicative measures between MIPS and other programs where possible. We intend to continue to align MIPS and the Medicaid EHR Incentive Program to the greatest extent possible. As we have noted in section II.E.5.g. of this final rule with comment period, the requirements for the Medicaid EHR Incentive Program for EPs were not impacted by the MACRA. There is a requirement to submit CQMs to the state as part of a successful attestation for the Medicaid EHR Incentive Program. While the MIPS objectives for the advancing care information performance category are aligned to some extent with the Stage 3 objectives in the Medicaid EHR Incentive Program, they are two distinct programs, and reporting will stay separate.
"In addition, we recognize that under MIPS, there will be more eligible clinicians subject to the requirements of EHR reporting than were previously eligible under the Medicare and/or Medicaid EHR Incentive Program, including hospital-based MIPS eligible clinicians, nurse practitioners, physician assistants, clinical nurse specialists, and certified registered nurse anesthetists. Since many of these non-physician clinicians are not eligible to participate in the Medicare and/or Medicaid EHR Incentive Program, we have little evidence as to whether there are sufficient measures applicable and available to these types of MIPS eligible clinicians under our proposals for the advancing care information performance category. As a result, we have provided additional flexibilities to mitigate negative adjustments for the first performance year (CY 2017) in order to allow hospital-based MIPS eligible clinicians, nurse practitioners, physician assistants, clinical nurse specialists, certified registered nurse anesthetists, and other MIPS eligible clinicians to familiarize themselves with the MIPS program. Section II.E.5.g.(8) of this final rule with comment period describes our final policies regarding the re-weighting of the advancing care information performance category within the final score, in which we would assign a weight of zero when there are not sufficient measures applicable and available."
Advantages of registry reporting vs. claims include:
There are many advantages to submitting your MIPS data via a qualified CMS registry. These include:
MDinteractive supports all 2017 MIPS Quality registry-based individual measures.
Currently, customer support (via 1-800-634-4731 or online chat) is available from 9-5 EST on Monday-Friday. As we move closer to the MIPS deadline (March 2, 2018), customer support hours will be expanded. Hours will be communicated on our website.
All providers must sign a consent giving MDinteractive permission to submit their data to CMS. Consents signed by an individual provider from previous PQRS or MIPS submissions are still valid. Practices with 2 or more in the TIN who decide to report as a group in 2017 will have to sign a new (group) consent. Only 1 consent, signed by an authorized representative, is necessary if reporting as a group.
MDinteractive provides CMS with the reporting and performance rate calculations for the measures submitted by a provider (using the combination of the individual NPI/TIN as the identifier). Individual patient information is not submitted to CMS.
When doing the EHR MU Attestation and reporting PQRS using MDinteractive please choose option 2 (I will submit my clinical quality measure data right now through attestation) because a provider using MDinteractive Qualified PQRS registry or the MDinteractive Specialized registry will NOT satisfy the eCQM EHR MU reporting requirement.
"We noted that the Medicaid EHR Incentive Program for EPs was not impacted by the MACRA and the requirement under section 1848(q) of the Act to establish the MIPS program. We did not propose any changes to the objectives and measures previously established in rulemaking for the Medicaid EHR Incentive Program, and thus, EPs participating in that program must continue to report on the objectives and measures under the guidelines and regulations of that program. Accordingly, reporting on the measures specified for the advancing care information performance category under MIPS cannot be used as a demonstration of meaningful use for the Medicaid EHR Incentive Programs. Similarly, a demonstration of meaningful use in the Medicaid EHR Incentive Programs cannot be used for purposes of reporting under MIPS. Therefore, MIPS eligible clinicians who are also participating in the Medicaid EHR Incentive Programs must report their data for the advancing care information performance category through the submission methods established for MIPS in order to earn a score for the advancing care information performance category under MIPS and must separately demonstrate meaningful use in their state’s Medicaid EHR Incentive Program in order to earn a Medicaid incentive payment. The Medicaid EHR Incentive Program continues through payment year 2021, with 2016 being the final year an EP can begin receiving incentive payments (§ 495.310(a)(1)(iii)).
We solicited comments on alternative reporting or proxies for EPs who provide services to both Medicaid and Medicare patients and are eligible for both MIPS and the Medicaid EHR Incentive Payment. The following is a summary of the comments we received regarding our proposal to separate the reporting requirements of MIPS and the Medicaid EHR Incentive Programs:
Comment: Many commenters stated the reporting burden imposed on MIPS eligible clinicians who also participate in the Medicaid EHR Incentive Programs, would have to report separately to achieve points in the advancing care information performance category, and to receive an incentive payment in the Medicaid EHR Incentive Programs. Some commenters urged CMS to align reporting requirements and submission methods across both programs to eliminate duplication in reporting effort. Some commenters requested that CMS eliminate the need to report duplicative quality measures by modifying its proposal to require that if quality is reported in a manner acceptable under MIPS or an APM, then it would not need to be reported under the Medicaid EHR Incentive Program. Other commenters expressed concern that varying reporting requirements for MIPS eligible clinicians, for hospitals and Medicaid EPs who participate in the EHR Incentive Programs will bring hardship to clinician staff, as well as EHR vendors.
Response: We understand that reporting burden is a concern to MIPS eligible clinicians and CMS remains committed to exploring opportunities for alignment when possible. However, MIPS and the Medicare and Medicaid EHR Incentive Program are two separate programs with distinct requirements. The reporting requirements and scoring methods of the Medicaid EHR Incentive Program and those finalized for the advancing care information performance category in the MIPS program differ significantly. For example, in the Medicaid EHR Incentive Programs, EPs must report on all objectives and meet measure thresholds finalized in the 2015 EHR Incentive Programs final rule. In the advancing care information performance category, MIPS eligible clinicians must report on objectives and measures, but are not required to meet measure thresholds to be considered a meaningful EHR user. We remind commenters that while MIPS eligible clinicians would be required to meet the requirements of the advancing care information performance category to earn points toward their MIPS final score, there is no longer a requirement that EPs demonstrate meaningful use under the Medicaid EHR incentive program as a way to avoid the Medicare EHR payment adjustments. However, MIPS eligible clinicians who meet the Medicaid EHR Incentive Program eligibility requirements are encouraged to additionally participate in the Medicaid EHR Incentive Program to be eligible for Medicaid incentive payments through program year 2021.
Comment: A few commenters proposed that MIPS eligible clinicians who are participating in the Medicaid EHR Incentive Program be exempted from reporting to MIPS until after the completion of their final EHR performance period. Others proposed allowing clinicians to choose either to report in the Medicaid EHR Incentive Program or the advancing care information performance category of MIPS. One commenter suggested awarding MIPS eligible clinicians 30 points toward the advancing care information performance category score if they successfully attest to meaningful use in the Medicaid EHR Incentive Program.
Response: As previously mentioned, objective and measure requirements of the Medicaid EHR Incentive Program and those finalized for the advancing care information performance category in the MIPS program vary too greatly to enable one to serve as proxy for another. We are finalizing our Medicaid policy as proposed."
Yes. PQRS must also be reported in order to avoid the non-reporting penalty. PQRS and Meaningful Use are separate CMS programs.
Beginning in 2017, with the introduction of MIPS, Meaningful Use will be replaced by a component called Advancing Care Information or ACI. Reporting ACI will have the potential of earning the provider/practice up to 25 points in their overall composite score. ACI can be attested to via MDinteractive.
MIPS clinicians who are part of a group practice and have assigned their billing rights to the group’s TIN will be assessed as part of the group, and will not have their Advancing Care Information score reweighted to zero. Groups have the option to include or not include data from the following MIPS clinicians that qualify for an automatic reweighting:
More info can be found on this CMS Presentation:
A practice does not have to register directly with CMS to report as a group. This option is open to all practices with 2 or more providers billing within the same TIN. If you have previously reported as individuals and will be reporting as a group in 2017, we ask that you contact us at email@example.com to let us know so that we can modify your account.
Note that if you are reporting one component of MIPS as a group, you will be evaluated as a group for all of the components.
The Value-Based Modifier will apply to all physicians in 2018. Non-reporting (of PQRS) in 2016 will automatically result in a -2% VM payment adjustment for groups of 1-9 providers and a -4% adjustment for groups of 10 or more. This is in addition to the -2% PQRS penalty for not reporting.
The VBM payment adjustment is applied through quality-tiering. Quality-tiering is the methodology used to evaluate a group or solo practitioner’s performance on quality and cost measures for the Value Modifier. PQRS quality data and Medicare cost data is used to determine a provider's (or group of providers) overall score. This system rewards high performance with increased payments and reduces payments to lower scorers.
Groups with 2 or more EPs could receive an upward adjustment (up to 4x the adjustment factor), a (up to 4%) downward adjustment, or no adjustment . Solo providers could receive an upward adjustment (up to 2x the adjustment factor) or no adjustment.
CMS typically releases information regarding your submission in the form of a PQRS feedback report in the 4th quarter (early Fall) of the following year. When these reports become available, you can contact the QualityNet Help Desk to access your feedback report. MDinteractive also has a link on our homepage titled PQRS Feedback for instructions on how to obtain your reports.
Available sometime in early Fall 2017.
PQRS Feedback Reports webpage:
A few comments:
1 - All 2016 PQRS reports and QRURs with value modifier information will be found here:
2 - If a provider thinks they are getting a penalty, please forward us the PQRS feedback report and the Supplementary Exhibit 11. Individual Eligible Performance on the 2016 PQRS Measures.
3- Providers can potentially have PQRS and/or Value Modifier penalties. Please note that the appeals webpages are different for each one of these programs.
A cluster is a collection of clinically related measures. A provider will avoid the PQRS penalty if he or she reports all of his or her Medicare patients for all of the measures contained within a cluster. The link for 2016 clusters and how it relates to the MAV can be found here: MAV.
MAV is the Measures Applicability Validation process. A clinical relation/domain test is applied when a provider submits less than 9 measures across 3 NQS domains or 9 measures across less than 3 domains. The MAV is used to determine whether or not a provider could have reported additional measures. When successfully reporting using a “cluster” of clinically related measures and a cross-cutting measure, a provider should pass the MAV.
"n/a" indicates that you had no patients eligible for the measure. For example, you will get that result on the mammography, urinary incontinence and osteoporosis screening questions for the preventive care measures group if your patient sample only included males. It is an acceptable value and will not negatively impact your PQRS submission results.
Providers must report one cross-cutting measure if they have at least one face-to-face encounter (based on patient encounter codes) with a Medicare patient. A cross-cutting measure would be in addition to a cluster of clinically related measures or as part of 9 Individual Measures across three NQS domains. Providers reporting using Measures Groups do not have to include a cross cutting measure in addition. A list of the broadly applicable cross cutting measures can be found here: cross-cutting measure.
Please reference the 2016 PQRS List of Face-To-Face Encounter Codes for the billable codes that identify face-to-face encounters for the purposes of 2015 PQRS reporting. This list includes general office visits, outpatient visits, and surgical procedure codes.
Please note that cross-cutting measures apply in general to many Medicare patients. For example if you have 100 Medicare patients, you would expect to report cross-cutting measure #226 Tobacco Use: Screening and Cessation Intervention on at least 50 Medicare patients (50% reporting rate).
There are however some cross-cutting measures that apply to smaller patient populations:
Reporting less than 9 measures (or fewer than 3 domains) is subject to the Measures Applicability Validation Process or MAV. CMS applies a "clinical relation/domain test" to determine whether additional measures could have been reported. If all of the measures within a cluster have been successfully reported by a provider, he or she will pass the MAV and avoid the PQRS penalty.