QPP SURS Newsletter January 2021


  1. Upcoming Events
  2. Small Practice Spotlight – Hematology & Oncology Associates of Northeastern Pennsylvania
  3. Quality Payment Program’s Response to COVID-19
  4. How to Kick-Off Year 5 of MIPS
  5. Data Spotlight: Small Practice Participation and Performance in MIPS
  6. Resources for Specialists to Consider in 2021
  7. Monthly Observance – National Glaucoma Awareness Month

Upcoming Events

Doctor Talking to Patient


Upcoming Webinar:

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

Additional Upcoming Events and Links to Past Events

Small Practice Spotlight – Hematology & Oncology Associates of Northeastern Pennsylvania

Hematology & Oncology Associates of Northeastern Pennsylvania is a seven-physician specialty group located in Dunmore, Pennsylvania, dedicated to caring for patients with cancer and blood disorders. Alice Hopkins, the practice administrator, shared her practice’s experience participating in MIPS and how the team overcame obstacles, including limited measures in their electronic health record (EHR) and high patient costs. While the COVID-19 pandemic became the practice’s priorty,  the practice has continued to collect MIPS measure data thanks to its pre-existing workflows, CMS telehealth billing resources, and help from their Technical Assistance (TA) Contractor. Below are some tips from Alice on how to succeed in MIPS as a specialty practice.

Understand your MIPS measures and the capacity of your EHR

When Alice checked her team’s progress on their selected MIPS measures in performance year 2020, she found they were still performing relatively well despite COVID-19 thanks to the workflow processes that the practice established in previous years. The practice continues to capture data from active oncology patients through their EHR, an oncology-specific software that reports select MIPS measures. While it can be a challenge for her specialty practice to find relevant measures, they are currently tracking the following quality measures:

  • Cervical cancer screening (Quality ID: 309)
  • Colorectal Cancer Screening (Quality ID: 113)
  • Oncology: Medical and Radiation – Pain Intensity Quantified (Quality ID: 143)
  • Closing the Referral Loop: Receipt of Specialist Report (Quality ID: 374)
  • Controlling High Blood Pressure (Quality ID: 236)
  • Use of High-Risk Medications in the Elderly (Quality ID: 238)
  • Tobacco Use: Screening and Cessation Intervention (Quality ID: 226)

Help reduce the “fear factor” associated with telehealth

Alice admitted that it took both providers and patients some time to get accustomed to telehealth visits, but once the program was established and providers grew more comfortable with administering telehealth appointments, the program became more successful. Recently, one provider successfully walked an 87-year-old patient through the process of setting up audio and video for an appointment. Outreach to family members and caregivers who can assist may be necessary to ensure the telehealth visit is successful.

Consider prescribing less expensive therapeutic equivalents when possible

Alice shared that one of the biggest MIPS challenges for her practice was related to the Cost performance category. It can be costly to treat oncology patients, but the practice made a conscious effort to try and manage drug costs and began using biosimilars instead of more expensive biologics. While using less expensive therapeutic equivalents means lower reimbursement for the practice, it ultimately reduces the cost of care of the practice’s Medicare patients, which contributes positively to their MIPS performance.

If you are a small oncology practice, consider Alice’s tips for ways to succeed with MIPS reporting in 2021.

Quality Payment Program’s Response to COVID-19

The COVID-19 public health emergency (PHE) has affected the provision of healthcare by clinicians throughout the United States in unprecedented ways. In response to the pandemic, the Centers for Medicare & Medicaid Services (CMS) has implemented many flexibilities for clinicians participating in the Quality Payment Program (QPP) and the Merit-based Incentive Payment System (MIPS). The flexibilities for the 2020 and 2021 performance years are summarized below.

Availability of Extreme and Uncontrollable Circumstances (EUC) Exception – Clinicians who have been impacted by the COVID-19 PHE may request reweighting of one or more MIPS performance categories for the 2020 performance year. CMS has extended the application deadline for the EUC exception to February 1, 2021, at 8pm ET.

  • Individual clinicians, groups, and virtual groups may apply for an EUC exception for any or all performance categories if the pandemic is preventing them from collecting data for an extended period of time or could negatively impact their Cost performance. If an application is approved, the applicable performance category will be reweighted to 0% and will not contribute to the final score unless the individual or group submits data for those categories.
  • APM entities may request reweighting of all performance categories if at least 75% of the MIPS-eligible clinicians qualify for reweighting in the Promoting Interoperability category. Data submission would not override performance category reweighting. If an application is approved, the APM entity would receive a final score equal to the performance threshold and a neutral payment adjustment.

Doubled Complex Patient Bonus – CMS is increasing the number of points available for the complex patient bonus in the 2020 performance year. The maximum number of points available to be added to the MIPS 2020 final score is being doubled from 5 to 10 points in recognition of the increase in patient complexity resulting from COVID-19.

New Improvement Activity: COVID-19 Clinical Data Reporting with or without Clinical Trial – CMS has added a new high-weighted improvement activity for the 2020 and 2021 performance years. Clinicians may receive credit for this activity if they have:

  • Participated in a COVID-19 clinical trial using a drug or biological product to treat patients with COVID-19, and report findings through a clinical data repository or clinical data registry for the duration of the study; OR
  • Participated in the care of COVID-19 patients and submitted relevant clinical data to a clinical data registry for ongoing or future COVID-19 research.

For clinicians who participate in both the COVID-19 Clinical Data Reporting with or without Clinical Trial activity and the existing Participation in a 60-day or greater effort to support domestic or international humanitarian needs activity, CMS will give full credit for the MIPS Improvement Activities performance category.

Inclusion of Telehealth Services in the Cost Performance Category for the 2021 Performance Year – CMS has updated existing measure specifications in the Cost performance category to include telehealth services where these services are applicable to existing episode-based cost measures and the Total Per Capita Cost measure.

Please visit the Quality Payment Program COVID-19 Response webpage for additional information on the flexibilities that CMS has implemented in all performance years, as well as the 2021 Quality Payment Program Final Rule Resources for additional information on the 2021 QPP final rule.

How to Kick-Off Year 5 of MIPS

The fifth year of MIPS kicked off on January 1, 2021. While many solo providers and small practices have participated in MIPS in prior years, others may be newly eligible for the program this year. No matter your previous experience with MIPS, consider the following tips to help get you off on the right foot in 2021.

Understand your eligibility

To check your preliminary eligibility for MIPS for performance year 2021, enter your ten-digit National Provider Identifier (NPI) in the QPP Participation Status Lookup Tool on the QPP website. CMS calculates your eligibility for MIPS by reviewing your Medicare Part B claims and Provider Enrollment, Chain, and Ownership System (PECOS) data during two determination periods during the performance year. For more information on your MIPS eligibility, see the 2021 MIPS Eligibility Decision Tree.

Determine how you will participate

You can participate in MIPS as an individual, group, virtual group, or Alternative Payment Model (APM). To learn more about your participation options, click here.

Decide how you will track and submit data

Solo providers and small practices have multiple options for how to collect and submit MIPS data for each performance category. For example, small practices can report quality measure data through Medicare Part B claims, clinical quality measures (CQMs), electronic clinical quality measures (eCQMs), or Qualified Clinical Data Registry (QCDR) measures. For the Promoting Interoperability (PI) and Improvement Activity (IA) performance categories, practices can submit data at the end of the performance period by signing into qpp.cms.gov and attesting to information or uploading a data file. Another option is for a third-party to perform a direct submission on the provider or practice’s behalf. As a reminder, you do not need to submit any data for the Cost performance category. CMS collects and evaluates this data on behalf of clinicians. For more information on MIPS collection and submission types for each performance category, review the CMS Quick Start Guides for the Quality, Improvement Activities, and Promoting Interoperability performance categories.

Start collecting your MIPS data

The Quality performance category requires 12 months of data collection, so start today! If you participated in MIPS last year, it is important to double check that your MIPS measures and activities are still available to report and haven’t changed from previous years.You may need to make adjustments to your measure documentation practices or consider selecting new measures if your previous measures are topped out. To view the quality measures available to report in 2021, refer to the 2021 Medicare Part B Claims Measure Specifications and Supporting Documents, or the 2021 Clinical Quality Measure Specifications and Supporting Documents. For the PI and IA performance categories, plan to identify at least one 90-day continuous period to collect data. For more information, refer to 2021 Promoting Interoperability Measure Specifications and the 2021 Improvement Activities Inventory.

Get ready to submit last year’s data, if applicable

If you participated in MIPS in performance year 2020, remember that the window to submit your performance year 2020 MIPS data opened on January 4, 2021, and closes on March 31, 2021. Take steps to prepare your MIPS data for submission, and double check that you have access to the QPP Portal. For assistance, refer to the 2020 Data Submission FAQs and the CMS video “Introduction and Overview of 2020 Data Submission.” You will need an active HARP account and login credentials to submit your data. For more information on how to create or reactive your HARP account, see the Quality Payment Program Access User Guide.

By checking your MIPS eligibility, confirming how you will participate and submit MIPS data, and beginning the collection of MIPS data, you will be in a great position for the 2021 MIPS performance year. Remember to reach out to your Technical Assistance (TA) Contractor for no-cost, personalized assistance with MIPS. Find your TA Contractor here

Data Spotlight: Small Practice Participation and Performance in MIP

As Year 5 of MIPS commences this month, it can be helpful to look back at the first three years of MIPS and review the progress that small practices have made in terms of MIPS participation and performance. The data below are summarized from annual CMS MIPS participation and performance infographics, including the 2017 QPP Performance Data Infographic, the 2018 QPP Performance Data Infographic, and the 2019 QPP Participation Infographic. The following tables show how small practices have made gains in MIPS performance and participation year-over-year.

Small Practice MIPS Participation and Performance

Percent Participation81%89%99%
Mean MIPS Score43.4665.6968.99

During the first year of MIPS, approximately 81 percent of MIPS-eligible small practices participated in MIPS thanks in part to the outreach and assistance provided by Technical Assistance (TA) Contractors. By 2019, 99 percent of MIPS-eligible clinicians in small practices participated in QPP, matching the participation rate of large practices. There were similar increases in MIPS performance results for small practices during this time period. In 2017, the average MIPS score for a small practice was 43 points while the average score for large practices was 74 points. In 2019, the average score for small practices was 69 points, a 59 percent increase over a three-year period, while the average score for large practices was 86 points.

Small Practice Score Breakdown: 2017 vs. 2018

Score Categorization20172018
Negative Score19%13%
Neutral Score8%3%
Positive Score30%26%
Exceptional Score44%58%

While final score information is not yet available for the 2019 performance period, looking specifically at the performance results from the first and second years of the program, the percent of MIPS-eligible small practices that received a negative payment adjustment decreased from 19 percent of all small practices in 2017 to 13 percent in 2018. The share of MIPS-eligible practices that received a positive or exceptional score increased from 74 percent in 2017 to 84 percent in just one year.

Take a moment to celebrate the success of your practice and small practices around the country. For more information on MIPS participation and performance results, review the 2017-2019 QPP infographics found in the Resource Library on the QPP website.

Resources for Specialists to Consider in 2021

Some MIPS-eligible specialists and specialty practices struggle to identify clinically relevant MIPS measures to report, including podiatrists, rheumatologists, surgeons, and pathologists. Even when applicable measures are identified, some electronic health record (EHR) vendors do not offer enough relevant measures to report, posing another challenge for specialists. With MIPS performance thresholds increasing in performance Year 2021 from 45 points in 2020 to 60 points in 2021, specialty practices may want to review the resources available to them to support their MIPS performance.

Take advantage of free assistance provided by your Technical Assistance (TA) Contractor

TA Contractors offer personalized, no-cost assistance to solo providers and small practices. TA Contractors produce resources for specialists, including specialty guides that outline relevant MIPS measures and activities for certain specialties. TA Contractors can also work with you directly to identify which MIPS measures you could consider reporting. Find your TA Contractor here

Review the CMS Specialty Measure Sets

CMS posts dozens of specialty measure sets for specialists to report on the QPP webiste. While MIPS-eligible clinicians are required to report a minimum of six quality measures, specialists have the option of reporting a full specialty measure set, which can contain fewer than six measures. This option prevents specialists from being penalized for submitting less than six quality measures. To find your specialty measure set, click on the Explore Measures and Activities tool on the QPP website.

Check out the resources provided by your national specialty association

Many specialty associations offer free MIPS resources targeted to their members, including free or reduced cost Qualified Registries or Qualified Clinical Data Registries (QCDRs) that collect and report MIPS measure data. For example, the American Academy of Ophthalmology (AAO) offers the Intelligent Research in Sight (IRIS) registry for free to its members, which can help streamline MIPS reporting by offering additional measures and enabling practices to submit their MIPS data through the registry. As a bonus, registries may offer additional quality measures that may not be available in a provider’s EHR software.

MIPS Value Pathways on the horizon

Specialists may be pleased to learn that CMS is planning to implement MIPS Value Pathways (MVPs) in 2022. The MVPs framework aims to connect measures across the MIPS performance categories for different specialties or conditions and reduce the burden of MIPS reporting on clinicians. This year, CMS is establishing MVP development criteria to support stakeholder collaboration in developing MVPs and proposing to establish a process for MVP candidates to be considered for future rulemaking.

While it can seem challenging to meet the new MIPS performance threshold of 60 points, remember that flexibilities still exist for small practices. Small practices will continue to receive six bonus points in the Quality performance category and can receive three (3) points for every quality measure submitted, even if it doesn’t meet data completeness criteria. Small practices will continue to be able to submit hardship exception applications to reweight the Promoting Interoperability performance category. Small practices will continue to receive 20 points for medium-weighted improvement activities and 40 points for high-weighted activities

Monthly Observance – National Glaucoma Awareness Month

This month is National Glaucoma Awareness Month and a good opportunity to ensure your patients are receiving appropriate ophthalmic evaluations. Glaucoma is the leading cause of blindness and affects about 3 million Americans, according to the Centers for Disease Control and Prevention (CDC). Glaucoma is caused by a buildup of fluid in the eye that damages the optic nerve. Patients who are over the age of 60 and those with diabetes are more likely to have glaucoma. Additionally, black individuals are 6 to 8 times more likely to get glaucoma than white individuals.

There is no cure for glaucoma and early detection is key to helping patients prevent this eye disease. MIPS includes two quality measures dedicated to improving care for patients with glaucoma. They include:

  • Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation (Quality ID: 12)

Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more office visits within 12 months.

  • Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of Care Plan (Quality ID: 141) – Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the pre-intervention level) OR if the most recent IOP was not reduced by at least 15% from the pre-intervention level, a plan of care was documented within the 12 month performance period.

If you are a MIPS-eligible optometrist or ophthalmologist, consider reporting on these two MIPS quality measures to help your patients identify and treat glaucoma at the earliest stage possible. For more information on glaucoma from the National Eye Health Education Program, click here.

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