QPP SURS Newsletter July 2019

QPP SURS Quality Payment Program


Upcoming Events

Doctor Talking to Patient


Reminder: LAN Webinars will not be held in July 2019.

August 2019 LAN Webinar: Maximizing Your Quality Score: Beyond the Basics 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: https://qppsurs.wordpress.com/resources/

Quality Payment Program Participation in 2018: Results at a Glance

The 2018 infographic is now available and provides highlights and preliminary data on Quality Payment Program participation and performance in 2018.

A few areas to highlight:

  • Clinician success in MIPS has continued to rise with 97% exceeding the performance threshold score of 15 points to receive a positive payment adjustment based on performance in 2018.
  • MIPS final scores increased across all practice sizes and types of participation (individual, group, and for clinicians participating in MIPS through an APM).
  • Nearly 90% of clinicians in small practices participated in 2018, which was an increase from 81% in 2017.
  • Small practices scored better in 2018 than 2017. Nearly 85% surpassed the scoring threshold for a positive payment adjustment, up from nearly 74% in 2017.

2018 Performance Scores and Feedback Now Available!

If your practice submitted 2018 Merit-based Incentive Payment System (MIPS) data through the Quality Payment Program website (either directly or through a third-party vendor), you can now view your performance feedback and MIPS final score by logging into the QPP Portal using your HCQIS Access Roles and Profile (HARP) credentials. These are the same credentials that allowed you to submit your 2018 MIPS data.

If you don’t have a HARP account, refer to the QPP Access User Guide for information on how to obtain a user ID and password to view your final score and feedback and help you prepare for QPP reporting in 2019.

For additional information, check out the following CMS resources designed to help practices understand their 2018 performance scores and feedback:

If you have questions about your performance feedback or MIPS final score, please contact the Quality Payment Program by:

You can also reach out to your Technical Assistance Contractor (TAC) for free assistance with any questions about your feedback report. To identify your regional Technical Assistance Contractor, click the following link: https://qpp.cms.gov/about/small-underserved-rural-practices.

Small Practice Spotlight: Infectious Disease Specialists of Atlanta

Is your practice seeking practical tips on how to succeed in MIPS and maximize use of your EHR? Consider adopting one of the strategies employed by Infectious Disease Specialists of Atlanta, a small practice in Georgia that received a MIPS group score of 100 in 2017! Donna Schreckengost, Chief Operating Officer, played a big role in setting the practice up for success and recommends the following tips for how other small practices, regardless of specialty, can achieve high MIPS scores:

  • Help clinicians document MIPS measures through workflow reminders: Donna created workflow documentation to help her clinicians remember what to ask patients during appointments and what diagnosis codes to enter in the electronic health record (EHR) for MIPS reporting. These step-by-step workflow documents included screenshots from the EHR to help the clinicians appropriately document the data.
  • Routinely monitor MIPS measures: Donna frequently runs reports on MIPS measures using her EHR to monitor performance and make sure scores are not lower than expected. For example, Donna runs reports in her EHR to ensure eligible patients are correctly being counted towards performance measures and, if not, re-trains the staff and clinicians on correct patient data collection and documentation procedures so they can improve their scores.
  • Get buy-in from clinicians: Donna stressed the importance of having everyone in the practice take ownership of MIPS reporting. She reminds clinicians of the impact a MIPS downward payment adjustment will have on the practice’s finances.
  • Reduce costs by requesting full patient records for referrals: Infectious Disease Specialists of Atlanta always request full patient records when accepting referrals to not duplicate lab work or other procedures. Donna also refers patients to in-house labs or clinical studies to reduce the patients’ out-of-pocket costs.

Careful documentation in the EHR and frequent monitoring of your practice’s performance on MIPS measures are key to ensuring your practice gets full credit for the care you provide to your patients. Try leveraging Donna’s strategies to achieve a high MIPS score in 2019!

May 2019 LAN Notable Q&As

The following questions were asked by the audience during the May 2019 LAN webinar titled “How to Maximize Your Score in the Cost Category: Practical Advice for Solo and Small Group Practices.” For access to the full Q&A document and previous LAN webinar presentations, see the QPP SURS website.

Q: Can you share information on the cost data we should expect in the 2018 MIPS performance feedback reports?

A: The 2018 MIPS performance feedback is now available. To view your performance feedback, visit the QPP Portal and sign with the same credentials that allowed you to submit and view data during the submission period. Your performance feedback includes beneficiary-level cost data reports for viewing and download by clinicians and groups who were scored on the MIPS Total Per Capita Costs for All Attributed Beneficiaries (TPCC) measure and the MIPS Medicare Spending per Beneficiary (MSPB) cost measure in 2018. Individuals and groups can compare their costs for each measure with the benchmark provided in the performance feedback user interface (UI) to better understand their performance relative to their peers, which include TINs or TIN-NPIs that had at least 20 eligible cases for TPCC and/or all TINs or TIN-NPIs that had at least 35 eligible cases for MSPB. These data may be used to identify care coordination opportunities for your beneficiaries and streamline resource use. For more information, please see the 2018 Performance Feedback FAQs which has detailed information about how to understand your cost category performance feedback.

Q: Are we responsible for all the costs during a hospital admission, even if our provider is not directly involved with the patient?

A: The process for attributing measures to a clinician varies be measure type. For the Medicare Spending Per Beneficiary (MSPB) measure, the eligible clinician who provided the most Part B physician/supplier services during the period between the index admission date and the discharge date is attributed the episode of care. All Medicare Part A and B claims for items provided during the time period is attributed to that eligible clinician. For procedural episode groups, episodes are attributed to each MIPS eligible clinician who renders the “trigger service,” as identified by CPT/HCPCS procedure codes defined in the measure specifications. For acute inpatient medical condition episode groups, episodes are attributed to each MIPS eligible clinician who bills Evaluation and Management (E&M) claim lines during a trigger hospitalization under a TIN that renders at least 30 percent of the inpatient E&M claim lines in the hospitalization.

Q: What is the Cost measure case size minimum?

A: For a cost measure to be scored, an individual MIPS eligible clinician or group must have enough attributed cases to meet or exceed the case minimum for that cost measure. The case minimum for the Total Per Capita Cost measure is 20. This means that for a MIPS eligible clinician participating in MIPS as an individual, 20 beneficiaries must be assigned to the individual MIPS eligible clinician’s TIN-NPI for this measure to be scored. For groups of clinicians participating in MIPS as a group, a total of 20 beneficiaries must be assigned to TIN-NPIs across the TIN-NPIs under the group’s TIN for the measure to be scored. The minimum case volume for the MSPB measure is 35, meaning that 35 MSPB episodes must be attributed to a MIPS eligible clinician or group for that measure to be scored. The minimum case volume for procedural episode-based measures is 10. This means that 10 episodes must be attributed to a MIPS eligible clinician or group for the measure to be scored. For a group, a total of 10 procedural episode-based episodes must be attributed across all clinicians – both MIPS eligible clinicians and eligible clinicians – in the group. The minimum case volume for acute inpatient medical condition episode-based measures is 20.

Resources For Specialists: Which Registry is Right for Your Practice?

Are you having trouble finding MIPS measures relevant to your specialty? Your first resource should be the Explore Measures & Activities tool on the QPP website, which offers Specialty Measure sets composed of relevant MIPS quality measures for 39 different specialties. Another great resource to consider is your national specialty association’s Qualified Registry (QR) or Qualified Clinical Data Registry (QCDR). Many specialty societies have created or endorsed their own registries to help their members collect clinical data and report quality measures to CMS. Some of these registries can be accessed for free or for a discounted rate for specialty society members.

There are many advantages to using registries for MIPS reporting. In fact, registries were the most popular method of collecting MIPS quality measure data among small practices in 2017! Most registries can submit MIPS data to CMS on your practice’s behalf across all three performance categories that require data submission (Quality, Promoting Interoperability, and Improvement Activities). Some registries can automatically pull data from compatible EHRs, saving you time and effort. Additionally, QRs and QCDRs are required to provide MIPS-eligible clinicians with feedback reports at least four times a year, on all performance categories, which helps clinicians and groups monitor their progress on MIPS measures.

Are you curious which registry is right for your specialty? The table below lists a few specialties and an example of a corresponding CMS-approved QR and/or QCDR. Please note that some specialties have multiple CMS-approved QRs and QCDRs. To view the full list of CMS-approved Qualified Registries, click here.  To view the full list of 2019 CMS-approved Qualified Clinical Data Registries, click here.  


Specialty Registry Link
Allergy, Asthma, and Immunology American Academy ofAllergy, Asthma, and Immunology (AAAAI) Quality Clinical Data Registry Powered by Arbor Metrix http://www.aaaai.org  
Anesthesiology Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) https://www.aqihq.org  
Cardiology PINNACLE Registry and Diabetes Collaborative Registry www.acc.org  
Dermatology AAD’s DataDerm™ (American Academy of Dermatology) http://www.aad.org/practicecenter/quality/dataderm  
Neurology Axon Registry http://www.aan.com/policy-and-guidelines/quality/axon-registry2/axon-registry/  
Oncology QOPI® Reporting Registry (American Society of Clinical Oncology) https://www.asco.org/advocacy-policy/asco-in-action/sign-now-available-qopi-reporting-registry-qualified-clinical-data-registry  
Optometry AOA MORE – Measures and Outcomes Registry for Eye care http://www.aoa.org
Ophthalmology American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight) http://www.aao.org/iris-registry/  
Primary Care American College of Physicians Genesis Registry, Powered by Premier, Inc. http://www.medconcert.com/Genesis
Physical Therapy Physical Therapy Outcomes Registry (American Physical Therapy Association) http://www.ptoutcomes.com  
Psychology PsychPRO (American Psychiatric Association) http://www.psychiatry.org/PsychPRO  
Radiology American College of Radiology National Radiology Data Registry http://www.acr.org    
Urology American Urological Association Quality (AQUA) Registry http://www.auanet.org  


Monthly Observance: National Safety Month

June is National Safety Month, and an opportunity for you to improve your MIPS score by engaging your patients on safety and how to prevent injuries, such as falls. MIPS supports these safety efforts by offering a variety of measures and activities for reporting that align with the goals of National Safety Month.

A few examples of patient safety quality measures and improvement activities available for MIPS reporting are shared below. Please use the QPP Explore Measures & Activities Tool to assist you with planning your MIPS reporting.

2019 Quality Measures:

  • Evaluation or Interview for Risk of Opioid Misuse (Quality ID: 414): All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, Screener and Opioid Assessment for Patients with Pain-Revised [SOAPP-R]) or patient interview documented at least once during Opioid Therapy in the medical record.
  • Falls: Screening for Future Fall Risk (Quality ID: 318): Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period.
  • Falls: Risk Assessment (Quality ID: 154): Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months.

2019 Improvement Activities:

  • Implementation of fall screening and assessment programs (IA_PSPA_21): Implementation of fall screening and assessment programs to identify patients at risk for falls and address modifiable risk factors (e.g., clinical decision support/prompts in the electronic health record that help manage the use of medications, such as benzodiazepines, that increase fall risk).
  • CDC Training on CDC’s Guideline for Prescribing Opioids for Chronic Pain (IA_PSPA_22). Completion of all the modules of the Centers for Disease Control and Prevention (CDC) course “Applying CDC’s Guideline for Prescribing Opioids” that reviews the 2016 “Guideline for Prescribing Opioids for Chronic Pain.”

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