QPP SURS Newsletter February 2019

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Reminder: Start Your 2018 Quality Payment Program Data Submission!

After all of your hard work last year collecting data for the MIPS performance categories, it is now time to submit your data! The MIPS data submission period for the 2018 performance year is currently open and will remain open until April 2, 2019 at 8pm EDT. CMS has worked to make data submission quick and easy at https://qpp.cms.gov. By logging into the data submission portal, you will be able to start your data submission and update it any time until April 2.

As a reminder, you have the option of submitting your MIPS data directly through the QPP portal, or having a third party submit your data for you (third parties include your EHR vendor, Qualified Registry (QR) or Qualified Clinical Data Registry (QCDR). If you are submitting quality performance category measure data via Part B claims, remember claims must be processed by CMS within 60 days after the close of the performance period on December 31, 2018. To be safe, it’s a good idea to submit any outstanding 2018 claims as early as possible during the submission window to allow enough time for your Medicare Administrative Contractor (MAC) to process the data. CMS recommends your check with your MAC if you have questions or need additional guidance. Remember, you can check your quality measure performance in real-time by logging into the QPP portal. CMS is updating 2018 performance feedback on a monthly basis for providers submitting their quality measures via Part B claim.

It is important to review the quality measure updates for Year 3 as you begin to select, collect, and report data on measures for the 2019 performance period. More information on the 2019 MIPS Quality Category can be found on the 2019 Quality Performance Category Fact Sheet. Remember to reach out to your Technical Assistance Contractor for free assistance if you have any questions about selecting quality measures. Information for your region’s Technical Assistance Contractor can be found at https://qpp.cms.gov/about/small-underserved-rural-practices.

SURS Practice Spotlight: Cheyenne Eye Clinic

Cheyenne Eye Clinic is a five-provider optometry and ophthalmology practice in Cheyenne, Wyoming. The clinic received a MIPS score of 98.7 in 2017 by taking advantage of key resources that were designed by national ophthalmology specialty societies. Stacey Ostby, the clinic manager, identified the following strategies that her practice employed to achieve success with MIPS reporting:

  • Leverage your national specialty society: Stacey’s practice looked to the national ophthalmology and optometry associations for advice on how to excel with the MIPS program, including the American Academy of Ophthalmology. These societies have robust support systems tailored specifically for the relevant specialties, which helped the practice prepare for and excel in MIPS. Stacey utilized contact lists available through the national specialty societies to email other practice administrators, learn what measures they were reporting, and troubleshoot common obstacles. Stacey recommends that other small practices take advantage of the resources available through their own national specialty societies.
  • Utilize your specialty registry: The Cheyenne Eye Clinic uses the Intelligent Research in Sight (IRIS) registry, which is designated as a Qualified Clinical Data Registry (QCDR) by CMS, Developed by the American Academy of Ophthalmology for MIPS reporting, this registry pulls MIPS measure data from her practice’s EHR and submits it directly to CMS. The IRIS registry also allows her practice to contact the registry staff directly for support if her practice has any concerns about their data or performance. Qualified Registries (QR) and QCDRs give practices greater visibility into their data and, in some cases, allow practices to compare their results with other practices around the country. Registries also allow practices to easily aggregate data from a variety of sources, and some registries can report across all MIPS performance categories using one tool. Click here for a list of CMS approved 2019 QRs or here for a list of 2019 QCDRs.
  • Educate staff on advantages of participating in MIPS: Stacey motivates her physicians to participate in MIPS by showing them the financial consequences of not engaging in the program. She uses data to provide a realistic estimate of how much money the practice stands to lose if they do not participate and do not get a high score. She also informs her providers of the potential bonuses for being an exceptional performer, which has helped to get her staff on board with participating in MIPS.

As your practice gets started with MIPS in 2019, see if your practice can replicate Cheyenne Eye Clinic’s success and make MIPS an added value for your practice and for your patients!

FAQs from November 2018 National QPP SURS LAN Webinar

The following questions were asked by the audience during the November 2018 LAN webinar titled “Overview of the 2019 Final Rule: Implications for Solo and Small Group Practices.” For access to the full Q&A document and previous LAN webinar presentations, see the QPP SURS WordPress website: https://qppsurs.wordpress.com/resources/.

1. Are there any in depth instructions to make it easier for those who are new to the submission process?

There are several resources available in the QPP resource library including the MIPS Participation and Overview Fact Sheet, the Claims Data Submission Fact Sheet, and the 2018 QPP Access User Guide. Additionally, CMS has a posted a series of videos to the QPP Resource Library to help clinicians understand how to manage and submit their 2018 Merit-based Incentive Payment System (MIPS) data through the QPP website between now and April 2, 2019. To access these videos, visit the CMS Resource Library or click the following links below.

  1. Uploading Files for Data Submission
  2. Reviewing Overview Data
  3. Reviewing Quality Category Data
  4. Reviewing Promoting Interoperability Category Data
  5. Reviewing Improvement Activities Category Data
  6. Manual Attestation of the Promoting Interoperability Category
  7. Manual Attestation of the Improvement Activities Category
  8. Deleting Submitted Data in the System
  9. Reviewing and Submitting Data as a Registry
  10. Navigation to Individual and Group Submission

Please visit the CMS QPP Resource Library to access all the CMS Quality Payment Program resources. If you have any questions or need assistance, we encourage you to reach out to your region’s Technical Assistance Contractor for free technical assistance. Information for your region’s Technical Assistance Contractor can be found at https://qpp.cms.gov/about/small-underserved-rural-practices.

2. Is there a feature to track claims submission data for Quality via the QPP portal during the year?

Yes, you can see provisional quality measure performance category results based on Medicare Part B claims submitted in the QPP Portal at https://qpp.cms.gov/. This information is updated on a monthly basis as more claims data are submitted but will not be finalized until after the completion of the overall QPP submission period. Please note that performance feed-back for 2019 claims will not be available until after the 2018 submission period closes in the spring of 2019.

3. What are the benefits for a provider that “opts-in?”

Beginning with the 2019 MIPS performance period/2021 MIPS payment year, if an individual eligible clinician, group or APM Entity exceeds at least one but not all of the low-volume threshold criteria and elects to report on applicable measures and activities under MIPS by electing to opt-in, then the individual MIPS eligible clinician, group or APM Entity will be considered MIPS eligible clinicians and will be assessed in the same way as all other MIPS eligible clinician(s) for the applicable payment year. Clinicians and groups that elect to opt-in will receive a MIPS payment adjustment based on their 2019 performance. Please be advised that the decision to elect to opt-in is binding and irreversible; thus, clinicians considering this option should explore program requirements, measures and activities to ensure that it is applicable and meaningful for them. You should also consider reaching out to your technical assistance organization about the possibility of opting-in.

Updates to the 2019 Promoting Interoperability (PI) Performance Category

For the 2019 performance year, CMS has updated the Promoting Interoperability (PI) performance category to streamline reporting requirements and continue to support electronic health record interoperability. Below are a few of the major changes to the PI category for the 2019 performance year1:

Mandatory use of 2015 CEHRT:

  • 2015 CEHRT is required for the PI category in 2019. 2015 Edition functionality must be in place by the first day of the PI performance period, and it must be certified by the last day of the performance period. The performance period for PI is a minimum of a continuous 90-day period. The timing of this 90-day period is up to you. For example, if you begin your PI reporting on April 1, 2019, you must have 2015 CEHRT in place on April 1, 2019 and certified by June 30, 2019. If you start reporting your PI measures on October 1, 2019, you have until December 31, 2019 to have CEHRT certified to the 2015 Edition.
  • The PI hardship exception will continue to be available for small practices. This means that if your practice has 15 or fewer eligible clinicians, you can request that the PI category be reweighted to zero. The PI weight would be reallocated to the Quality Performance category. Information on how to apply for a hardship application will become available later in the 2019 performance period.
  • Objectives and Measures:
    • In 2019, there will be only one set of objectives and measures based on the 2015 Edition CEHRT. In previous years, there were two measure set options for reporting based on the clinician or group’s CEHRT edition.
    • There are four objectives for the PI category in Year 3: 1) e-Prescribing, 2) Health Information Exchange, 3) Provider to Patient Exchange, and 4) Public Health and Clinical Data Exchange.
    • The Year 3 final rule eliminates the base, performance, and bonus scores that were a part of the PI performance category in Year 1 and Year 2 of the program.

New Scoring Methodology for Promoting Interoperability:

  • In 2019, you must submit collected data for certain measures from each of the four objectives (unless an exclusion is claimed) for 90 continuous days or more during 2019. In addition to submitting measures, clinicians must:
    • Submit a “yes” to the Prevention of Information Blocking Attestation,
    • Submit a “yes” to the ONC Direct Review Attestation, and
    • Submit a “yes” for the security risk analysis measure.

Beginning in 2019, Scoring is Simplified:

  • Each measure will be scored by multiplying the performance rate (calculated from the numerator and denominator you submit) by the available points for the measure. For the Public Health and Clinical Data Exchanges measures, the individual or group will simply submit a “yes” or a “no” to attest to completion of the measures.
  • Failure to submit at least a “1” in the numerator of a required measure will result in a zero being earned for the PI performance category unless an exclusion is submitted.
  • If exclusions are claimed, the points for those measures will be reallocated to other measures.

New Bonus Points:

  • Clinicians, groups, and virtual groups can earn five bonus points each for the submission of these optional new measures:
    • Query of Prescription Drug Monitoring Program (PDMP)
    • Verify Opioid Treatment Agreement

For more information on changes to the PI category in the Final Rule, work with your Technical Assistance Contractor: https://qpp.cms.gov/about/small-underserved-rural-practices or check out the Final Rule Overview.

1Quality Payment Program Year 3: Final Rule Executive Summary

2Exclusions are available for the following 2019 PI Measures: e-Prescribing, Support Electronic Referral Loops by Receiving and Incorporating Health Information, Immunization Registry Reporting, Electronic Case Reporting, Public Health Registry Reporting, Clinical Data Registry Reporting, and Syndromic Surveillance Reporting.

Monthly Observance — American Heart Month

February is American Heart Month – a good time to celebrate heart health progress to date and prioritize actions for the rest of the year. MIPS continues to reward providers for activities that support cardiac health, and you can join in this effort by improving referrals to cardiac rehabilitation for eligible patients. The 2019 MIPS measure that supports referrals to cardiac rehabilitation is:

  • Cardiac Rehabilitation Patient Referral from an Outpatient Setting (Quality ID: 243)

Furthermore, a cardiac rehabilitation change package is now available from the Million Hearts initiative and the American Association of Cardiovascular and Pulmonary Rehabilitation (AAVCPR). You can access the toolkit here: https://millionhearts.hhs.gov/files/Cardiac_Rehab_Change_Pkg.pdf

CMS will be updating its Explore Measures tool on https://qpp.cms.gov/ in the coming months to allow clinicians and groups to search for updated 2019 cardiology measures. For more information on cardiac quality measures to report in the 2019 performance year, reach out to your Technical Assistance Contractor at: https://qpp.cms.gov/about/small-underserved-rural-practices.

Upcoming Events


March 2019 LAN Webinar: MIPS Question and Answer Town Hall Event for Solo and small Group Practices

April 2019 LAN Webinar: Lessons Learned: How to Succeed in MIPS for Solo and Small Group Practices

Additional Upcoming Events and Links to Past Events

Upcoming and past CMS events related to MACRA, MIPS, and APMS will be listed here starting in the new year: https://qpp.cms.gov/.

Past QPP SURS events are listed here: https://qppsurs.wordpress.com/resources/

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