QPP SURS Newsletter April 2020


  1. Upcoming Events
  2. COVID-19 Pandemic: Update on 2019 MIPS Reporting
  3. Small Practice Spotlight: Lafayette Pain Care
  4. February LAN Q&A
  5. Security Risk Analysis (SRA) Measure
  6. How to Find Relevant MIPS Measures Using Single Source Documents
  7. Monthly Observance: National Minority Health Month

Upcoming Events

Doctor Talking to Patient


*There will be no April 2020 LAN Webinar

Upcoming Webinar: Understanding how to Implement Telehealth Services: Implications for Solo and Small Group

  • Tuesday, May 26, 2020, 3:30 p.m. – 4:30 p.m. ET
  • Thursday, May 28, 2020, 11:00 a.m. – 12:00 p.m. ET

Additional Upcoming Events and Links to Past Events

COVID-19 Pandemic: Update on 2019 MIPS Reporting

In response to the 2019 Novel Coronavirus (COVID-19) pandemic, CMS extended the 2019 MIPS data submission deadline from March 31 to April 30, 2020. MIPS-eligible clinicians now have an extra 30 days to prepare and submit their 2019 MIPS data.

If you are a MIPS-eligible clinician and do not submit data as an individual in two or more performance categories by April 30, 2020, you won’t need to take any additional action to qualify for the MIPS Automatic Extreme and Uncontrollable Circumstances policy. You will be automatically identified and will receive a neutral payment adjustment for the 2021 MIPS payment year.

The Automatic Extreme and Uncontrollable Circumstances policy does not apply to group participation. If you have already started submitting your 2019 MIPS data, you can submit an application for the 2019 Extreme and Uncontrollable Circumstances hardship exception by April 30, 2020. The 2019 MIPS Extreme and Uncontrollable Circumstances Application is available to clinicians who have already submitted some data as an individual or part of a group, and to clinicians participating as a virtual group.

For more details about the Extreme and Uncontrollable Circumstance Application and information about changes to the Quality Payment Program (QPP) in response to the COVID-19 pandemic, please review the Quality Payment Program COVID-19 Response. For information on the COVID-19 waivers and guidance, and the Interim Final Rule, released on March 30, please go to the CMS COVID-19 flexibilities webpage: https://www.cms.gov/about-cms/emergency-preparedness-response-operations/current-emergencies/coronavirus-waivers.

Small Practice Spotlight: Lafayette Pain Care

One small practice staff in Indiana has found that participating in MIPS helps them track their patients and improve health outcomes. The providers at Lafayette Pain Care, a pain care center with multiple locations throughout Indiana, participated in MIPS as a group in 2018 and received a score of 100. Brittney Irvin, the Office Administrator, shared her experience tracking MIPS measures for the practice’s providers and tips for how other small practices can improve their MIPS scores.

  • Identify measures that align with your care improvement strategy – Lafayette Pain Care selected MIPS measures that align with their pain management goals, including documenting current medications in the medical record, checking if a follow-up care plan is documented, conducting opioid therapy follow-ups and evaluations, and ensuring there are care plans in place for their patients age 65 and older. Brittney said it has been a game-changer to have MIPS measures aligned with the practice’s strategy to support their day-to-day workflow.
  • Create MIPS coding cheat sheets – Brittney created laminated index cards with the necessary billing codes that the practice must report for every patient visit to get full credit for their MIPS measures. These “cheat sheets” are placed in each exam room so that providers and medical scribes can refer to them when documenting MIPS measure information during patient visits. Brittney maintains a spreadsheet with MIPS measure data and uploads the spreadsheet to her Qualified Clinical Data Registry (QCDR) at the end of the performance period.
  • Leverage technology to track MIPS measures – Lafayette Pain Care’s electronic health record (EHR) has a user-friendly dashboard that highlights how providers are performing on the MIPS measures using a color-coding system (e.g., green=pass or measure in good standing, red=fail or more actions required). The EHR dashboard allows Brittney to drill down on the practice’s Medicare patients, view measure results, and identify opportunities for improvement. The practice’s QCDR also offers tools to help her identify which patients are due for a checkup, especially those taking opioids. If you are interested in exploring registries, CMS has published a list of approved Qualified Registries (QRs) and QCDRs on the QPP website.

Brittney also noted the importance of her local Technical Assistance Contractor (TAC), who helped her identify MIPS bonus points for which the practice was eligible and helped her transition from claims to EHR reporting.  Brittney’s advice for other small practices looking to improve their MIPS score is to start early, monitor measures frequently, and utilize your free Technical Assistance Contractor.  To find your Technical Assistance Contractor, click here.

February LAN Q&A

The following questions were among those asked by the attendees of the February 2019 LAN webinar, entitled “2019 MIPS Data Submission: Advice for Solo or Small Group Practices.” The answers have been edited here for length and context. For access to the full Q&A document and previous LAN webinar presentations, see the QPP SURS website.

1. I was not an eligible practitioner for 2019 but I opted into MIPS reporting. Will I always be required to opt in even if I am not eligible in the future years?

If you opt-in for the 2019 Performance Year, the election will only apply for the 2019 Performance Year. You will not be required to participate in future years if you opt-in only for the 2019 performance period, unless you become eligible by exceeding the low-volume threshold. If you are eligible to opt-in in future years, you would have to opt-in again for each performance year.

MIPS eligibility is determined each performance year independently of future performance years. For Performance Year 2019, the MIPS eligibility determination period consists of two 12- month segments:

  • Segment #1: A 12-month segment beginning on October 1, 2017 and ending on September 30, 2018, plus a 30-day claims run- out; and
  • Segment #2: A 12-month segment beginning on October 1, 2018 and ending on September 30, 2019. Segment #2 does not include a claims run out period.

2. Will the QPP Portal show what our vendor has submitted? Or do we need to look at our vendor information to see what has been submitted?

Whether you are uploading data directly to the QPP Portal, or a third-party vendor is submitting data on your behalf, you should log into the QPP Portal to review your submitted MIPS data. For instructions on how to access the QPP Portal, please see the QPP Access User Guide.

3. What supporting documentation is necessary for the small practice hardship exception for Promoting Interoperability (PI)? The only requirement for the small practice hardship exception is being designated a small practice by CMS.

MIPS-eligible clinicians, groups, and virtual groups may submit a PI Hardship Exception Application citing one of the following specified reasons:

  • MIPS-eligible clinician in a small practice
  • MIPS-eligible clinician using decertified EHR technology
  • Insufficient internet connectivity
  • Extreme and uncontrollable circumstances
  • Lack of control over the availability of CEHRT

Small practices that apply for a PI Hardship Exception are not required to submit any supporting documentation. We recommend you retain documentation of your circumstances in case CMS requests data validation or in the event of an audit. For more information on suggested documentation to maintain in case of audit, see the 2019 MIPS Data Validation Criteria. Please note that the PI Hardship Exception Application for Performance Year 2019 closed on December 31, 2019. If you receive a Hardship Exception for the PI category, the PI category would receive a weight of 0 percent in calculating your final score, and the 25 points will be reallocated to the Quality category, making the Quality category worth 70 points. More information on MIPS Exceptions can be found at https://qpp.cms.gov/mips/exceptionapplications.

Security Risk Analysis (SRA) Measure

The Security Risk Analysis (SRA) is a prerequisite for participation in the MIPS Promoting Interoperability (PI) performance category. The objective of the SRA is to ensure that health care providers are protecting all patient health information, particularly electronic patient health information (ePHI). To fulfill this measure, you must attest “YES” to conducting or reviewing an SRA at your practice, implementing security updates as necessary, and correcting identified security deficiencies.

Please note that if your practice is applying for a PI hardship exception for this performance period, you should NOT attest to the SRA measure. Reporting any measure in the PI category will nullify your exception and could negatively impact your MIPS score. You can still conduct an SRA during the performance period, but do not attest to completing the measure.

If you are not seeking a PI category hardship exception, you must conduct or review an SRA on an annual basis. If you have completed an SRA last year, you can review and update the prior analysis for changes in risks. Additionally, an SRA should be conducted with any major change, such as significant changes in infrastructure or technology (e.g., implementation of a new EHR system). You should conduct (or review) your SRA in accordance with the HIPAA Security Rule, which requires an accurate and thorough analysis of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of ePHI, including data encryption.

Once you have completed your analysis, you must implement security updates as necessary and correct any security deficiencies that you identify. Please note that you do not need to complete all security updates and corrections immediately, or even within the reporting year. Instead, you must develop and follow a plan to complete the updates and corrections. Please note that in the event of an audit, you may need to demonstrate that your practice is taking steps to implement the plan. When planning your approach, a good place to start is by reviewing the SRA measure specifications and reviewing the Office of the National Coordinator for Health Information Technology and the HHS Office for Civil Rights’ Security Risk Assessment Tool, which was developed specifically for small and medium practices.

You may also want to consult with your Technical Assistance Contractor, many of whom provide free resources and step-by-step guides on how to complete the SRA, including Telligen’s QPP Resource Center presentation on the subject, or TMF’s Security Risk Analysis article. To find your Technical Assistance contractor, click here.

How to Find Relevant MIPS Measures Using Single Source Documents

Identifying relevant MIPS measures for your practice can be challenging, especially for specialty practices. There are several strategies you can use to identify relevant MIPS measures for your practice. Start by reviewing the 47 Specialty Measure Sets published by CMS. To find your specialty measure set, click on the Explore Measures and Activities tool on the QPP website and filter by your specialty.

Another way to identify relevant quality measures is by using “Single Source” documents available on the QPP website within the 2020 measure specifications and supporting documents zip files (see links below). Single Source documents allow you to identify potential MIPS measures based on your most common billing codes. While certain measures may not seem relevant at first, you may realize that your practice is already billing for these activities and reporting on these measures might help to increase your MIPS score.

Single Source documents are available for providers who report their MIPS measures using Medicare Part B claims and for providers reporting MIPS measures using a Qualified Registry (QR) or Qualified Clinical Data Registry (QCDR).

To find the Single Source documents, begin by opening the zip file relevant to your submission type:

Inside each zip file, you will find Excel documents with the words “Single Source” in the label. By opening these documents and filtering the measures based on your commonly used billing codes (CPT, ICD-10 and/or HCPCS codes), you can identify which MIPS measures are relevant to your practice. For a more in depth overview of how to use Single Source documents, check out TMF’s Question and Answer Guide on Single Source documents.  

Additionally, CMS has recently published a list of cross-cutting quality measures that are broadly applicable to all clinicians regardless of their specialty. Check out the 2020 Cross-Cutting Quality Measures to learn more. If you need additional help identifying relevant MIPS measures, reach out to your Technical Assistance Contractor (TAC). To identify your Technical Assistance Contractor, click here.

Monthly Observance: National Minority Health Month

April marks National Minority Health Month, an annual tradition of raising awareness about health disparities that continue to affect racial and ethnic minority populations. As COVID-19 continues to spread across the country, the pandemic is shining a light on health disparities among racial and ethnic minorities.

In many cities like Detroit, Chicago, and New Orleans, data shows that minorities who contract the virus experience poorer outcomes than their white counterparts.  Over 70% of COVID-19 related deaths are African-American, yet African Americans only represent 30-40% of the population in these areas.1

Due to institutional and structural racism and inequality, there are a number of risk factors that put African Americans and other minorities at an increased risk of death from COVID-19. These include higher rates of high blood pressure, diabetes and other chronic conditions, limited access to primary care, and greater risk of living in a food desert.

Below are MIPS-included quality measures that focus on preventing and treating conditions which may disproportionately impact minority groups. You may want to consider including these measures in your reporting to drive quality improvement and strengthen your MIPS score:

  • Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) (Quality ID: 001) – Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.
  • Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan (Quality ID: 128) – Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter Normal Parameters: Age 18 years and older BMI => 18.5 and < 25 kg/m2.
  • Controlling High Blood Pressure (Quality ID: 236) – Percentage of patients 18 – 85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period.
  • Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents (Quality ID: 239) – Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported: (1) Percentage of patients with height, weight, and body mass index (BMI) percentile documentation; (2) Percentage of patients with counseling for nutrition; and (3) Percentage of patients with counseling for physical activity.

You can also review the National Institute on Minority Health and Health Disparities and the U.S. Department of Health and Human Services Office of Minority Health for more ideas and resources that can help your practice improve outcomes and reduce health care disparities.

  1. https://news.ohsu.edu/2020/04/10/health-disparities-and-covid-19-a-crisis-within-a-crisis

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