QPP SURS Newsletter February 2020

QPP SURS Quality Payment Program


  1. Upcoming Events
  2. Small Practice Spotlight: Surprise Health Center, AZ
  3. New MIPS Measures in 2020
  4. December LAN Q&A
  5. New Resources for Specialists
  6. Monthly Observance: American Heart Month

Upcoming Events

Doctor Talking to Patient


CMS Quality Conference:

*There will be no March 2020 LAN Webinar

April 2020 LAN Webinar: Maximizing your Score in the Cost Category: Advice for Solo and Small Group Practices

Additional Upcoming Events and Links to Past Events

Small Practice Spotlight: Surprise Health Center, AZ

“Don’t expect to send one memo in January and be done with communication. Constant communication is key. Your providers will become your advocates for the program, working together as a unit.” – Joseph Wieleba

Joseph Wieleba is Director of Operations at Surprise Health Center, a multi-specialty primary care practice in Surprise, AZ. The four MIPS-eligible clinicians at this practice participated in MIPS as individuals and received exceptional scores in both 2017 and 2018. Below is Joseph’s advice for other small practices trying to improve their MIPS scores.

  • Start early and communicate often: Joseph recommends preparing early for MIPS and not leaving data collection until later in the year. While the Promoting Interoperability and Improvement Activities performance categories require data collection to be undertaken during any continuous 90-day period within the year, quality measure data must be collected over the full 12-month performance period. Joseph recommends collecting data on more than six quality measures and then selecting the highest-performing measures to report to CMS. The clinicians at Surprise Health Center collect their quality measure data using their electronic health record (EHR) and typically track nine to 10 measures each year and then report the highest-performing ones at the end of the performance period.
  • Keep providers engaged: Surprise Health Center is also part of a larger network that sends out weekly performance updates to keep clinicians engaged in MIPS. The group established a MIPS Monthly Committee made up of “MIPS champions” at each practice, including providers and staff from the front office and billing departments, who come together to discuss their progress on collecting and recording MIPS measures.
  • Get buy-in from staff: When Joseph’s practice selects MIPS improvement activities, they pick activities that benefit the entire practice and receive the most buy-in from staff. The practice sends out a questionnaire to staff to determine which activity they have the most interest in pursuing. When it is time to implement the activity, Joseph notes that having received buy-in from the staff makes it easier to implement these activities.
  • Take advantage of your Electronic Health Record (EHR): Surprise Health Center’s EHR software includes a MIPS dashboard to help track measures for each of the MIPS performance categories. The dashboard has hyperlinks for each MIPS measure, connecting staff to a complete explanation of measure requirements and recommended workflows for implementation. Surprise Health Center uses Practice Fusion’s Qualified Clinical Data Registry (QCDR) to submit their MIPS data for the Quality, Promoting Interoperability, and Improvement Activities categories. The QCDR allows Surprise Health Center to report their MIPS data directly to CMS through their EHR and achieve bonus points for end-to-end electronic reporting!

For more information on the CMS-approved 2020 QCDRs, click here.  Consider Joseph’s tips and strategies as you embark on MIPS reporting for the 2020 performance period!

New MIPS Measures in 2020

The 2020 Quality Payment Program Final Rule updated the number and type of MIPS measures that are available for reporting in the 2020 performance period. Several new measures are available for reporting while dozens of measures have been removed, including measures that are extremely “topped out,” meaning that there is almost no room for improvement in average clinician performance on these measures. CMS conducts an annual review of quality measures and removes those that are no longer meaningful to shift the focus to high-priority and outcome measures that will improve care for patients. If you reported on a measure that is now topped out or is no longer eligible to report, celebrate your high achievement on that measure, but remember you will need to find a suitable replacement for MIPS reporting going forward! For a full list of topped out measures, see the 2020 MIPS Historical Quality Benchmark file and scroll right to see the column indicating topped-out status. Examples of topped-out measures include:

  • Documentation of Current Medications in the Medical Record (Medicare part B claims, eCQM, and MIPS CQM) (Quality ID: 130)
  • Diabetes Eye Exam (Medicare part B claims, MIPS CQM) (Quality ID: 117)

Quality Measures:

  • There are three new Quality Measures available for reporting in 2020.
    • International Prostate Symptom Score (IPSS) or American Urological Association-Symptom Index (AUA-SI) Change 6 -12 Months After Diagnosis of Benign Prostatic Hyperplasia (eCQM) (Quality ID: 476)
    • Multimodal Pain Management (MIPS CQM) (Quality ID: 477)
    • Functional Status Change for Patients with Neck Impairments (MIPS CQM) (Quality ID: 478)
  • 42 quality measures have been removed in 2020.
  • CMS added seven new specialty measure sets for Audiology, Clinical Social Work, Chiropractic Medicine, Endocrinology, Nutrition/Dietician, Pulmonology, and Speech Language Pathology. To review the specialty measure sets, visit the Explore Measures tool on the QPP website and filter results by Specialty Measure Set.
  • For more information on active quality measures, see the 2020 MIPS Clinical Quality Measure Specifications and Supporting Documents, or the 2020 Medicare Part B Measures Specifications and Supporting Documents if you are reporting via claims.

Cost measures:

As in previous years, CMS will automatically calculate your measures and score in the cost category.

  • There are 10 new Episode-Based Measures.
  • The methodologies used to calculate the Total Per Capita Cost and Medicare Spending Per Beneficiary cost measures were revised.
  • For more information, see the 2020 MIPS Summary of Cost Measures.

Promoting Interoperability (PI) Measures:

Improvement Activities Measures:

  • There are two new Improvement Activities:
    • Drug cost transparency (IA_BE_25)
    • Tracking of clinician’s relationship to and responsibility for a patient by reporting MACRA patient relationship codes (lA_CC_19)
  • Seven existing Improvement Activities were updated:
    • Completion of an accredited safety or quality improvement program (IA_PSPA_28)
    • Anticoagulant management improvements (IA_PM_2)
    • Additional improvements in access as a result of QIN/QIO TA (IA_EPA_4)
    • Implementation of formal quality improvement methods, practice changes, or other practice improvement processes (IA_PSPA_19)
    • Participation in a QCDR that promotes use of patient engagement tools (IA_BE_7)
    • Use of QCDR data for ongoing practice assessment and improvements (IA_PSPA_7)
    • Completion of Collaborative Care Management Training Program (IA_BMH_10)
  • Fifteen improvement activities have been removed. For a list of available improvement activities to report in 2020, please see 2020 Improvement Activities Inventory.   

For more information about changes to MIPS in the 2020 performance period, check out the 2020 Quality Payment Program Final Rule FAQs. Additionally, check out the recently updated Explore Measures tool for the full list of 2020 MIPS measures, including new specialty measure sets.

December LAN Q&A

The following questions were among those asked by the attendees of the December 2019 LAN webinar, entitled “Implications of the Year 4 Final Rule for Solo and 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. Do the collection types remain the same in 2020 (i.e. claims, EHR, etc.)?

Yes, the collection types remain the same in 2020. “Collection type” refers to how quality performance category data can be collected and includes: electronic clinical quality measures (eCQMs); MIPS clinical quality measures (CQMs) (formerly referred to as “registry measures”); Qualified Clinical Data Registry (QCDR) measures; Medicare Part B claims measures; CMS Web Interface measures; the CAHPS for MIPS survey measure; and administrative claims measures. “Submission type,” on the other hand, refers to the mechanism by which the submitter type submits data to CMS, including, as applicable: direct, log in and upload, log in and attest, Medicare Part B claims, and the CMS Web Interface. 

2. How do you find the quality measures for 2020 and specialty sets?

You can find the 2020 quality measures in the 2020 MIPS Quality Measures List. You can also review the 2020 claims measures in the 2020 Medicare Part B Measure Specifications and Supporting Documents and the 2020 clinical quality measures (CQMs) in the 2020 Clinical Quality Measure Specifications and Supporting Documents. Additionally, the Explore Measures Tool on the QPP website has recently been updated with the 2020 MIPS measures for each of the performance categories.

3. Is there any information concerning facility reporting as opposed to group reporting?

A group is defined as a TIN with two or more eligible clinicians, including at least one MIPS eligible clinician, as defined by their NPIs who have reassigned their Medicare billing rights to the TIN. When reporting as a group, a group must meet the definition of a group at all times during the performance year and aggregate their performance data across the TIN (including clinicians who may not be eligible to participate in MIPS) in order to have their performance assessed as group. A group will be assessed as a group across all four MIPS performance categories, and the MIPS eligible clinicians in the group will receive the same payment adjustment based on the group’s performance.

Facility-based measurement is used to assess performance at the facility level for select MIPS eligible clinicians, groups, and virtual groups whose primary healthcare responsibilities take place in hospital settings. Beginning with the 2019 Performance Year, clinicians, groups, and virtual groups will be able to use their facility-based scores form the Hospital Value Based Purchasing (HVBP) Program as an alternative scoring mechanism for the Quality and Cost performance categories. For more information on Facility-based scoring, please see the 2019 Facility-Based Measurement Fact Sheet

New Resources for Specialists

Navigating MIPS reporting can be a challenge for specialists struggling to find MIPS measures that are applicable to their practice. To succeed in MIPS in 2020, consider utilizing one or more of the following resources:

CMS Specialty Measure Sets

Many quality measures may not apply directly to a given specialty. In recognition of this fact, CMS defines a number of specialty and sub-specialty measure sets including seven that are new in 2020: Audiology, Clinical Social Work, Chiropractic Medicine, Endocrinology, Nutrition/Dietician, Pulmonology, and Speech Language Pathology.

The purpose of these measure sets is to simplify the process of selecting measures for specialists. Keep in mind that use of these sets is optional. Those who choose to report specialty measure sets must submit data on at least six measures within the chosen set. If the set contains fewer than six measures, the clinician or practice should submit each measure in the set, but does not need to submit additional quality measures.

To learn more about the new specialty measure sets, see Table Group B in Appendix A of the 2020 Quality Payment Program Final Rule. To review the other 39 sets, filter by Specialty Measure Set in the Explore Measures Tool on the QPP website.

TAC Resources

Your Technical Assistance Contractor (TAC) offers free individualized support to small practices. You can find and contact your TAC here. Many TACs offer comprehensive specialty guides, which include measure recommendations and other guidance for dozens of specialties. For example, Mountain-Pacific Quality Health, a subcontractor of Network for Regional Healthcare Improvement (NRHI), offers their own specialty guides on their website under “Specialty Resources.”

National Specialty Society Resources

National specialty associations and societies compile MIPS resources designed exclusively for your specialty. Specialty associations also offer Qualified Registries (QR) and Qualified Clinical Data Registries (QCDRs) that help specialty practices identify and report MIPS measures. If you are having trouble finding relevant MIPS measures, your specialty society may be able to assist!

Monthly Observance: American Heart Month

February is American Heart Month, and an excellent opportunity to explore ways in which your MIPS participation can overlap with improving your patients’ heart health.

According to the US Department of Health and Human Services, heart disease is the leading cause of death for men and women in the United States. Every year, one in four deaths are caused by heart disease.

There are a broad range of activities and interventions that can improve heart health. MIPS includes a number of Quality Measures focused on promoting cardiac health. Read more about some of these measures below and consider including them in your reporting to improve care and strengthen your MIPS score:

  • Coronary Artery Disease (CAD): Antiplatelet Therapy (Quality ID 006): Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12-month period who were prescribed aspirin or clopidogrel.
  • Functional Status Assessments for Congestive Heart Failure (Quality ID 377): Percentage of patients 18 years of age and older with congestive heart failure who completed initial and follow-up patient-reported functional status assessments.
  • HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation (Quality ID 392): Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation. This measure is submitted as four rates stratified by age and gender:
    • Submission Age Criteria 1: Females 18-64 years of age
    • Submission Age Criteria 2: Males 18-64 years of age
    • Submission Age Criteria 3: Females 65 years of age and older
    • Submission Age Criteria 4: Males 65 years of age and older.
  • Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients (Quality ID 324): Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in asymptomatic, low coronary heart disease (CHD) risk patients 18 years and older for initial detection and risk assessment.

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