QPP SURS Newsletter December 2020


  1. Upcoming Events
  2. Extreme and Uncontrollable Circumstances (EUC) Application Deadline Extension
  3. Small Practice Spotlight – Fast Access Healthcare, Tennessee
  4. Overview of the 2021 QPP Final Rule
  5. How to Prepare for the Upcoming Performance Period
  6. How to Engage Patients in Telehealth
  7. Reminder: Update Your Contact Information in NPPES
  8. Recent Quality Payment Program Resource Library Additions
  9. Monthly Observance – World AIDS Day

Upcoming Events

Doctor Talking to Patient


Upcoming Webinar:

January 2021 LAN Webinar: Implications of the Year 5 Final Rule for Solo and Small Group Practices

February 2021 LAN Webinar: Key Insights for Success in MIPS and Lessons Learned: Advice for Solo and Small Group Practices*

  • Tuesday, February 9, 2021 – 11:00 a.m. – 12:00 p.m. ET
  • Thursday, February 11, 2021 – 4:00 p.m. – 5:00 p.m. ET

*Registration links are forthcoming

Additional Upcoming Events and Links to Past Events

Extreme and Uncontrollable Circumstances (EUC) Application Deadline Extension

CMS is extending the 2020 Merit-based Incentive Payment System (MIPS) Extreme and Uncontrollable Circumstances (EUC) Exception application deadline to February 1, 2021. CMS will be using the EUC policy to allow MIPS-eligible clinicians, groups, and virtual groups to submit an application requesting reweighting of one or more MIPS performance categories to 0% due to the current COVID-19 public health emergency. Additionally, APM Entities can now submit an application to request reweighting of all MIPS performance categories due to extreme and uncontrollable circumstances. Please note that the deadline for the Promoting Interoperability Hardship Exception application will remain December 31, 2020.  If you are already exempt from reporting Promoting Interoperability data, you don’t need to apply.

For more information, see the 2020 MIPS Extreme and Uncontrollable Circumstances Application Resources, including the Exceptions Application Fact Sheet and the recently published video on how to apply for the EUC Application.

Small Practice Spotlight – Fast Access Healthcare, Tennessee

Tami Barrett is Director of Technical Operations for Fast Access Healthcare, a group of six primary care clinics in Chattanooga, Tennessee and the surrounding areas. Altogether, the clinics see approximately 400 patients per week. While the COVID-19 pandemic has challenged the practice, their leadership team, comprised of their CEO and Supervising Physician Dr. Jonathan Kerley, VP of Operations Tina Smith, and Director of Technical Operations Tami Barrett, has helped the providers at Fast Access Healthcare adjust their workflows to continue to serve patients through telehealth and home visits. Below are their tips for other small practices on how to continue with MIPS reporting during this challenging year.

Consider piloting a home visiting program

Before the pandemic, Fast Access Healthcare was already considering a mobile branch of their practice. To ensure continued care during the COVID-19 pandemic (and continued collection of MIPS measures), Fast Access Healthcare piloted a home visiting program. They began by identifying patients who were good candidates for home visits, including anyone who was over the age of 65, immunocompromised, or homebound. By increasing home visits during the pandemic, Fast Access Healthcare continued to safely care for patients and collect data to satisfy MIPS measures, including screening for high blood pressure, anti-depressant medication management, and hemoglobin A1c measurement.

Make telehealth easy for patients and providers

When CMS announced the expansion of telehealth services, Fast Access Healthcare had its first telehealth visit within 24 hours. The practice set up separate Zoom accounts for all six clinics and drafted workflows for each practice, including telehealth trainings for providers and front desk staff. The clinics provided instructions for patients on how to access and use Zoom on their website, complete with screenshots on how to sign in to the telehealth visit. To ensure continuity of care, front desk staff scheduled follow-up appointments with patients when scheduling the telehealth visit (not at the end) so that patients with chronic conditions would continue to receive necessary care. The practice also put together a “living document” shared online reference sheet for front-line staff, billing staff, and providers that enumerates the telehealth services covered by each payer, whether public and private, and the documentation/codes/modifiers needed to receive reimbursement.  

Take advantage of Technical Assistance (TA) Contractors

The most important tip Tami recommends to small practices is to take advantage of TA Contractors, who provide personalized, no-cost assistance to small practices to help them succeed in MIPS. Tami’s TA Contractor helped her identify which patients were eligible to be counted in MIPS measures and how to maximize use of her electronic health record (EHR) for MIPS reporting.

We hope these tips and strategies from Fast Access Healthcare help you successfully kick-off Year 5 of MIPS in January 2021. Remember to reach out to your TA Contractor with any questions or support needs. Find your TA Contractor here.

Overview of the 2021 QPP Final Rule

In early December, the Centers for Medicare & Medicaid Services (CMS) released the 2021 Physician Fee Schedule Final Rule, which includes updates to the Quality Payment Program (QPP) and the Merit-based Incentive Payment System (MIPS). Below are a few highlights from the final rule, including upcoming changes to MIPS in Performance Year (PY) 2021.

MIPS Value Pathways (MVPs) are delayed until 2022

  • Due to the pandemic, CMS is delaying implementation of the MVPs until 2022. In the upcoming year, CMS will be inviting stakeholders to develop and submit MVP candidates for evaluation and potential inclusion in future rulemaking.

The MIPS performance threshold will increase to 60 points (an increase from 45 points in 2020)

  • To avoid a 9% negative payment adjustment, MIPS-eligible clinicians must score a minimum of 60 points in 2021. Additionally, the Quality performance category will be worth 40% of your total MIPS score in 2021 (a decrease from 45% in 2020). The Cost performance category will be worth 20% of your final MIPS score in 2021 (an increase from 15% in 2020).

CMS will increase the complex patient bonus for PY2020

  • Good news! If you were eligible for the complex patient bonus during the 2020 performance year, you get double-points! Previously, the bonus was worth up to 5 points; now you can earn up to 10 points in recognition of the complexity added to your patient population due to COVID-19.

New Alternative Payment Model (APM) Performance Pathway (APP)

  • MIPS-eligible clinicians participating in MIPS APMs now have the option to participate in the new APM Performance Pathway, which was designed to streamline reporting and scoring requirements for clinicians in MIPS APMs. The APP is mandatory for Shared Savings Program ACOs.
  • CMS is sunsetting the ACO Scoring Standard in 2021. MIPS-eligible clinicians in a MIPS APM will be able to participate in MIPs and submit data as an individual, group, virtual group, or through their APM Entity.  

Promoting Interoperability CEHRT Requirements

  • For the Promoting Interoperability category, you have until December 31, 2022, to update your Certified Electronic Health Record Technology (CEHRT) to the 2015 Edition Cures update certification criteria. In 2021, you have the following options:
    • Keep using CEHRT per existing 2015 Edition certification criteria
    • Upgrade to the 2015 Edition Cures Update certification criteria, or;
    • Use a combination of the above two options

For more information on the 2021 QPP Final Rule, see the 2021 Quality Payment Program Final Rule Resources, which include a fact sheet, FAQs, a policy comparison table, and the MIPS Value Pathways (MVP) Candidate submission template.

How to Prepare for the Upcoming Performance Period

The fifth year of the Quality Payment Program (QPP) kicks off on January 1, 2021. With the MIPS performance threshold increasing from 45 points in 2020 to 60 points in 2021, understanding recent changes to the program will help your practice prepare for the upcoming performance period. Use the following tips and reminders to get started and maximize your MIPS score in 2021.

1) Review your cost performance feedback 

  • In 2021, CMS is increasing the cost performance category weight from 15% to 20% of your total MIPS score. Reviewing your past performance feedback can help you identify patients with high health care costs and find strategies to improve care while lowering costs for these patients. 
  • With the COVID-19 pandemic continuing, CMS will include telehealth services that are directly applicable to existing episode-based cost measures and the Total Per Capita Cost (TPCC) measure. If your practice is not using telehealth services, you may want to consider ways to implement a telehealth program to benefit from this opportunity.

2) Look for new opportunities in the Improvement Activities (IA) and Promoting Interoperability (PI) performance categories

  • Review the changes to the IA category to ensure your activities and their requirements are still available. The Final Rule removed one improvement activity (CC_5 CMS Partner in Patients Hospital Engagement Network) and modified two other activities. See the 2021 Improvement Activities Inventory for more details.
  • Look for opportunities to increase your PI score. For example, the bonus points you can receive for reporting the optional Query of Prescription Drug Monitoring Program (PDMP) measure are increasing from 5 to 10 bonus points. In addition, CMS is adding a new Health Information Exchange (HIE) bi-directional measure worth 40 points.
  • For an overview of all changes for 2021, please review the 2021 Quality Payment Program Final Rule or the 2021 Quality Payment Program Final Resources available on the QPP website.

3) Review and select your 2021 Quality Measures

  • Make sure your MIPS quality measures are still available reviewing the changes for 2021 including changes to 113 existing MIPS quality measures, changes to specialty sets, removal of 11 quality measures, and the addition of two new administrative claims measures (one of which has a 3-year measurement period). 
  • For more information on MIPS quality measures, review the 2021 MIPS Cross-Cutting Quality Measures.   

4) Utilize your free resources

  • Reach out to your TA Contractor for free personalized assistance. Find your TA Contractor here.
  • Review the Resource Library on the QPP Website for 2021 Quality Payment Program Final Rule Resources, including a fact sheet, FAQs, a policy comparison table, and the MIPS Value Pathways Candidate submission template.
  • If applicable, you can also reach out to your EHR vendor for available MIPS resources.
  • Check out resources from your national specialty society’s website. Many national specialty associations post free resources for their members, including recommended quality measures or links to Qualified Registries (QRs) or Qualified Clinical Data Registries (QCDRs) to facilitate data collection and reporting.

How to Engage Patients in Telehealth

The COVID-19 pandemic has brought telehealth to the forefront of the health care delivery system. Telehealth, or the provision of health information, health education, and health care services using telecommunication technologies, helps to provide necessary care to patients while minimizing the transmission risk of infectious diseases, including COVID-19. It includes many services commonly provided in-person, such as routine office visits, mental health counseling, and preventive health screenings.

A telehealth program is meant to empower patients to take a more active role in their health care and requires patient engagement to be effective. Virtual office visits require a different approach to connecting with patients, asking clinicians to focus on new aspects of the patient relationship. As the pandemic continues and telehealth is likely to become a more permanent fixture in the health care landscape, it will be important to consider the following strategies to increase patient engagement with telehealth services within your practice.

Be familiar with your telehealth technology. It’s important to know how your system works so that you can troubleshoot common technological problems during a visit. Also, make sure that you have alternative means to reach the patient should the technology not work properly, such as the patient’s cell phone or home phone number.

Prepare your patients before a virtual visit. Not all patients have the same understanding of technology. It may be helpful to provide the patient with an orientation to your system before the visit, and it may help to have someone available during a virtual visit to provide technical support to the patient. In addition, you may want to consider sending a telehealth checklist before the visit, including such details as:

  • Testing communication equipment before the visit
  • Providing a list of whom to contact in case of technical difficulties
  • Finding a private, quiet, and well-lit environment
  • Being prepared with medical information, medications, and a list of questions for the doctor

Consider your video setting. Your on-screen environment is just as important as that of your physical office. Is your location well-lit and without distraction for both you and for the patient? Make sure that your camera is adjusted such that you fill the screen and it allows you to look directly at the patient.

Maintain proper on-screen etiquette. Maintaining patient engagement requires maintaining awareness of your actions and body language. Making and maintaining “eye contact” is critical for establishing a connection. During the visit, minimize the need to break the connection with your patient by preparing in advance and then giving the patient your undivided attention. For example, if you have to look away to write down notes, let your patient know what you’re doing.

Put your communication skills to use. Keep in mind that the virtual visit may be a new experience for your patients, so make sure they know what to expect at every step. Ask questions, be an active listener, and engage in shared decision-making.

Telehealth can be a powerful tool in the provision of care during the COVID-19 pandemic and beyond. By making it easier and more comfortable for your patients to access care, you will increase their engagement with telehealth.

Reminder: Update Your Contact Information in NPPES

The new CMS Interoperability and Patient Access Final Rule encourages providers to update their digital contact information in the National Plan and Provider Enumeration System (NPPES) on an annual basis. Providers are encouraged to enter or update their Direct Messaging Address in NPPES to help build a national directory of addresses so that providers can easily exchange electronic health information.

Direct Messaging Addresses are similar to generic work or personal email addresses, but these addresses allow for secure, encrypted exchange of patient health information. If you are unsure of your Direct Address, reach out to your EHR vendor or State Health Information Exchange (HIE).

Once you update your information, you’ll be able to look up other providers’ direct emails, which should make it easier to exchange health information and help you meet the requirements for the HIE measures in the Promoting Interoperability category. If your EHR does not include direct contacts for providers to whom you regularly refer patients, encourage your EHR vendor to update their records for those providers.

On September 30, 2020, Purdue Healthcare Advisors (partner of Altarum) held a webinar for clinicians on how to update their information in NPPES. Speakers offered the following tips:

  • To update your login information, access the NPPES website here: https://nppes.cms.hhs.gov/?userType=Provider#/
  • Log in to NPPES using the same username and password you have used in the past for NPPES, PECOS, and Meaningful Use.
    • Either the provider or their designated “access manager” may update information.
    • If you’re not sure of your username and password, your practice manager may have that information.
  • Fill out the form to update your contact information and hit “save.” You may get an error message saying the data you entered has not been submitted. This is OK! Click on the button that says “Complete NPI Application.” Don’t worry – this will update your contact information, but will not initiate a new NPI application.
  • Go through the remaining steps, then check the box to certify this form is being completed by or on behalf of a health care provider.
  • Check back later to make sure you have been added to the NPPES registry (this may take up to 48 hours). If you have not been added within 48 hours, please resubmit your information.

Need additional assistance? Find your TA Contractor here for free, personalized assistance. Additionally, watch this CMS Instructional Video on how to update your NPPES account.

Recent Quality Payment Program Resource Library Additions

The following resources were recently added to the QPP resource library:

  1. 2020 CMS Web Interface Support Call Schedule and Registration
  2. 2021 Qualified Registries and Qualified Clinical Data Registries (QCDR) Qualified Postings
  3. 2021 QCDR Measure Specifications
  4. 2021 Improvement Activities Inventory
  5. 2021 Cross-Cutting Quality Measures
  6. MVP Town Hall Preparation Guide
  7. MVP Candidate Submission Template and Instructions  

Monthly Observance – World AIDS Day

December 1 was World AIDS Day, an annual opportunity for people to unite against the spread of HIV, support those living with HIV, and remember those who have died from the disease. Founded in 1988, World AIDS Day was the first ever global health day.

There are an estimated 38 million people globally, and 1.2 million people in the U.S., living with HIV. HIV has a disproportionate impact on certain populations, particularly racial and ethnic minorities and gay and bisexual men. According to the Centers for Disease Control and Prevention (CDC), roughly 1 in 7 people with HIV are unaware that they are infected.

World AIDS Day and the entire month of December is an excellent time to ensure your patients are screened for HIV and receive treatment to help manage the disease. There are several MIPS quality measures related to HIV. Consider using one of these measures to improve your MIPS score and improve your patient care:

  • HIV Screening (Quality ID: 475) – Percentage of patients aged 15-65 at the start of the measurement period who were between 15-65 years old when tested for HIV.
  • HIV Medical Visit Frequency (Quality ID: 340) – Percentage of patients, regardless of age with a diagnosis of HIV who had at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visits.
  • HIV Viral Load Suppression (Quality ID: 338) – The percentage of patients, regardless of age, with a diagnosis of HIV with an HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year.
  • HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis (Quality ID: 205) – Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia, gonorrhea, and syphilis screenings were performed at least once since the diagnosis of HIV infection.

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