QPP SURS Newsletter July 2020


  1. Upcoming Events
  2. Small Practice Spotlight – Western Wayne Physicians, MI
  3. Reminder: Review Your 2019 MIPS Performance Feedback
  4. How to Participate in MIPS using Telehealth
  5. 2020 Quality Measures List for with Telehealth Guidance
  6. Safety Considerations when Reopening your Practice
  7. How to Engage Patients in Telehealth
  8. Monthly Observance – UV Safety Month

Upcoming Events

Doctor Talking to Patient


Upcoming Webinar: Topic To Be Determined

Additional Upcoming Events and Links to Past Events

Small Practice Spotlight – Western Wayne Physicians, MI

Western Wayne Physicians is a primary care practice of 12 physicians who work across three office locations in the suburban Detroit area. Dr. Robert Jackson shared his Allen Park office’s experience during the COVID-19 pandemic and how they are keeping patients and staff safe during a recent webinar by Medical Advantage Group, a partner of Altarum. Below are some of the strategies Dr. Jackson shared:

  • Find an alternate setting to treat sick patients and engage the community for support: In mid-March, Dr. Jackson realized that he had to figure out how to provide a space to test and treat patients showing potential symptoms of COVID-19 to reduce community spread. Several of Dr. Jackson’s patients volunteered to bring in supplies, including a trailer and carport, which were set up behind his Allen Park office to allow staff to conduct COVID-19, flu, and Respiratory Syncytial Virus (RSV) testing. After engaging his community for support with creating a testing space, additional patients started to volunteer supplies, including a heater and N-95 masks.
  • Get up to speed on new billing procedures and reimbursement: Dr. Jackson acknowledged that at first his practice was unsure of which codes to use for COVID-19-related treatment and testing. In the first few weeks of the pandemic, he knew he could bill for specimen collection, pulse oximetry testing, and temperature readings. When examining his patients and asking if they were experiencing fever, chills, sweats, or had any recent travel to COVID-19 hotspots, he billed the 99213 CPT code for an Office or Other Outpatient Visit. CMS has since provided guidance to clinicians on how to bill for COVID-19 related testing and treatment. Additionally, the practice has increasingly relied on telemedicine and phone conversations to provide care to patients. Dr. Jackson was thankful that Medicare increased reimbursement for telephone calls, as many of his patients do not have video functionality.  
  • Take additional steps to make patients feel safe: Dr. Jackson’s office staff conduct an initial screening of patients who come into the office by administering a survey either before the patient comes into the office or in the front entrance of the building before the patient enters. The office staff also take temperatures of incoming patients before admitting them into the office. Patients are required to wear masks and are then directed to the waiting room, where plastic chairs placed six feet apart have replaced the typical furniture to make it easier to disinfect each seat. The office has placed signs on waiting room chairs and exam rooms that say “this seat is clean” to help assure patients that these surfaces have been disinfected.

It can take ingenuity and creativity to revamp your office in light of COVID-19. Many small practices are facing similar challenges around reimbursement and patient safety. If you need assistance, do not hesitate to reach out to your Technical Assistance Contractor for free personalized support. Find your Technical Assistance Contractor here.

Reminder: Review Your 2019 MIPS Performance Feedback

Now is a good time to review your 2019 MIPS performance feedback to help improve your 2020 reporting and decide if you will want to request a targeted review. To view your scores, log in to the Quality Payment Program (QPP) website using your HCQIS Authorization Roles and Profile (HARP) credentials, and review your performance feedback for all of your associated practices. If you are unsure of your HARP credentials, or still need to set up a HARP account, please see the QPP Access User Guide.

If you decide that you wish to submit a targeted review after reviewing your final scores, here are a few things you can do to prepare for your submission:

  • Review your feedback
  • Identify potential errors and explanations of the error(s)
  • Gather supporting documentation such as:
    • Supporting extracts from the MIPS-eligible clinician’s electronic health record (EHR)
    • Copies of performance data provided to a third party by the clinician or group
    • Copies of performance data submitted to CMS
    • QPP Service Center ticket numbers

To submit a targeted review, sign into your HARP account, and complete the targeted review request form, which can be accessed from your performance feedback page.

Additionally, CMS implemented many flexibilities for the Quality Payment Program in response to the COVID-19 pandemic that may affect your 2019 performance feedback. Your 2019 MIPS performance feedback will reflect performance category reweighting due to either the automatic extreme and uncontrollable circumstances policy, or an approved extreme and uncontrollable circumstances exception application due to COVID-19. Clinicians with approved exceptions will see either of the following reflected in their performance feedback:

  • Automatic policy: Performance feedback will display a score of “N/A” for all performance categories for which an individual clinician did not submit data. Individual clinicians who didn’t submit any data will see a message that they qualify for the automatic extreme and uncontrollable circumstances policy.
  • Approved application: Performance feedback will display a score of “N/A” for all performance categories that were included in the application.

Your performance feedback will still include any data that you submitted, even if the performance category was reweighted.  Although you will not submit cost data, you will also see feedback on cost measures, provided that some data was submitted in another performance category.

To learn more about other flexibilities, review the QPP COVID-19 Response Fact Sheet. You can also reach out to your Technical Assistance Contractor for individualized support. To find the right person to talk to in your region, click here.

How to Participate in MIPS using Telehealth

The COVID-19 pandemic has increased practices’ use of telehealth services to provide safe, quality care to patients. Many services normally provided in-person can be provided via telehealth, including office visits, mental health counseling, and preventive health screenings. You can view a full list of telehealth services here.   

Considering the major shift from traditional office visits to telehealth services, many practices are wondering how telehealth will affect their MIPS participation moving forward. In particular, understanding which quality measures and improvement activities are included in telehealth services will help your practice succeed in MIPS. 

Telehealth and Quality Measures

Approximately one-third of the 2020 quality measures include telehealth visits. To meet the 20-case minimum requirement and capture as many telehealth visits as possible, practices should select the quality measures that include telehealth visit codes. You can refer to the 2020 Measure Specification Sheets and Supporting Documentation to learn which quality measures use telehealth visit codes. A few things to keep in mind:

  • The patient encounter code must use an approved telehealth code. Note: the current list includes 240 codes.
  • The patient encounter cannot state “WITHOUT Telehealth Modifier GQ, GT, 95, POS 02.”

If you’re not sure what codes are required for your selected MIPS measures, you can refer to the 2020 Measure Specification Sheets and Support Documentation for details.

Telehealth and Improvement Activities

There are many improvement activities that can be performed via telehealth, including Annual Wellness Visits (AWVs). Providers can use video conferencing or audio-only technology to conduct an AWV, as long as the platform is secure and providers are practicing in good faith. More information on CMS’s policy on telehealth remote communications during COVID-19 can be found here. In addition, patients can self-report vitals during an AWV conducted via telehealth, as long as they are documented as self-reported. Lastly, Hierarchical Condition Coding (HCC) with the AWV continues to be acceptable just as it was with face-to-face visits. Other relevant improvement activities include:

For more information on telehealth services, you can listen to and view the QPP SURS May LAN Webinar, Understanding How to Implement Telehealth Services: Implications for Solo and Small Group PracticesIn addition, for information on telehealth and billing, review the Medicare Telehealth and Remote Patient Monitory Coding and Guidelines Toolkit or contact your Medicare Administrative Contractor. If you need assistance, do not hesitate to reach out to your Technical Assistance Contractor for free personalized support. Find your Technical Assistance Contractor here.

2020 Quality Measures List for with Telehealth Guidance

CMS recently published a list of quality measures that includes telehealth for the 2020 performance period. When reviewing this list of quality measures, please note there may be instances where the quality action cannot be completed during the telehealth counter by MIPS-eligible clinicians and group practices. Specifically, telehealth eligible Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes may be included within the measure denominator, where the required quality action in the numerator cannot be completed via telehealth. For example, Q111: Pneumococcal Vaccination Status for Older Adults may require the administration of the pneumococcal vaccination at the denominator eligible encounter in order to meet performance for the measure. Therefore, it is the MIPS-eligible clinicians, groups, and virtual groups’ responsibility to make sure they can meet all other aspects of the quality action within the measure specification, including other quality actions that cannot be completed by telehealth. For more information, please review the Telehealth Guidance for Medicare Part B Claims and MIPS Clinical Quality Measure (CQMs) for 2020 Quality Reporting.

Safety Considerations when Reopening your Practice

With stay-at-home restrictions relaxing in states across the country, many small practices are making plans to either re-open their offices to in-person appointments or prepare for an increase in in-person visits. Reopening raises many questions for clinicians about patient and staff safety, best practices for infection control, patient outreach, liability, and other important considerations. To help practices through this process, the American Medical Association (AMA) has released a resource entitled “COVID-19: A physician practice guide to reopening.” Below are some recommendations from this resource to help you get started:

  1. Create and document a plan to re-open (and temporarily close again, if necessary). A clear plan will allow your staff and patients to know what to expect and can be a tool to protect you from liability. Your plan should include new workflows and safety measures, assessment of personal protective equipment, and clear procedures in the case an employee or patient is diagnosed with COVID-19.
  2. Open incrementally. Consider opening with a lighter patient load to give you and your staff time to identify and address any practical challenges presented by your workflows and procedures. Consider allowing administrative staff to continue to work remotely.
  3. Institute safety measures for patients and staff. Implement additional safety measures such as eliminating waiting rooms, requiring cloth face coverings, designating separate areas for “well” and “sick” patients, creating designated work stations for each staff member, and increasing cleaning frequency.
  4. Continue to utilize telehealth tools. Even as your practice begins to see patients in the office, consider continuing telehealth to screen and triage patients before their appointment. Patients who may have COVID symptoms can be re-directed to a COVID-19 testing site or a hospital.
  5. Coordinate testing. Contact your public health authority to identify the COVID-19 testing sites in your area. Make sure you understand their requirements and procedures so that you refer your patients to these sites when necessary.
  6. Limit visitors. Create and enforce a policy that limits the number of individuals who enter the practice but are not patients or employees. This includes creating a plan for vendors, suppliers, salespeople, and family members.
  7. Contact your medical malpractice insurance character. Talk to your carrier about your current coverage and any additional coverage you may need.
  8. Stay informed. Federal and state agencies and public health authorities continue to release new regulations, resources, and recommendations. Make sure you are staying up to date with federal, state, and local requirements, and those of any professional associations to which you belong. You may also want to consult the CDC’s updated guidance for health care systems that includes a framework to deliver non-COVID-19 health care during the COVID-19 pandemic.

How to Engage Patients in Telehealth

It can be challenging to engage some of your patients in telehealth, especially older adults who may prefer not to use the computer or video technology. The COVID-19 pandemic has spurred a sudden shift to telehealth, and your practice may be ready to utilize this method of delivery, but your patients may not be! Below are some tips for how to engage your patients in telehealth:

1) Educate patients on the benefits of telehealth: Telehealth not only gives patients the ability to stay at home and avoid potential exposure to infection while receiving health care consultations from their physicians, but it also provides patients the ability to access their medical records, schedule appointments, and message with their providers. Patients can even share images with their doctors and receive consultations over email or phone. At telehealth.hhs.gov, you can find patient-facing materials that prepare patients for telehealth and ease anxieties, such as “How to Prepare for a Video Visit.” Additionally, the Office of the National Coordinator for Health Information Technology created a “Patient Engagement Playbook” that clinicians and staff can use to increase patient engagement in health information technology.

2) Get caregivers and family members involved: The transition to telehealth is a great way to get caregivers and family members involved in a patient’s healthcare. Caregivers can participate in telehealth visits, ask questions, and help monitor the care of their loved ones. Family and friends can also help set up the technology required for telehealth visits.

Mountain-Pacific Quality Health (a subcontractor of NRHI) is working with AARP to engage older adults with health information technology through a partnership with local high schools. Read more about this partnership here.

3) Overcome barriers to telehealth in rural areas: There are serious challenges to implementing telehealth in rural areas, including lack of broadband. Some patients in rural areas do not have reliable phone connections, let alone internet connections and bandwidth for video transmission. While challenges remain, the Rural Health Information Hub provides resources to help address access to telehealth in rural areas. Check out their Telehealth Use in Rural Healthcare Topic Guide and the Rural Telehealth Toolkit.

For more advice on engaging patients in telehealth, reach out to your Technical Assistance Contractor for FREE personalized support. Find your Technical Assistance Contractor here.

Monthly Observance – UV Safety Month

July is UV Safety Awareness Month. Ultraviolet (UV) radiation is a form of electromagnetic radiation that is emitted both by the sun and some man-made sources like tanning beds. UV rays are not visible to the naked eye, and overexposure to them can cause skin damage and skin cancer. In fact, the Melanoma Research Foundation reports that nearly 90% of cutaneous melanomas are related to UV exposure.

As many people are spending more time outside, now is an excellent time to remind your patients of the basics of UV safety. The CDC recommends that all people, regardless of age or ethnicity, wear a broad-spectrum sunscreen with SPF 15 or higher while outdoors, even on cool or overcast days. It also recommends that direct exposure to the sun be limited through the use of shade, a hat, sunglasses, and clothing that offers skin coverage.

Additionally, MIPS includes several quality measures, listed below, that encourage testing and care coordination for patients with skin cancer. You may want to consider including these measures in your MIPS reporting to drive quality care and strengthen your MIPS score:

  • Melanoma: Coordination of Care (Quality ID: 138) – Percentage of patient visits, regardless of age, with a new occurrence of melanoma that have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis.
  • Skin Cancer: Biopsy Reporting Time – Pathologist to Clinician (Quality ID: 440) – Percentage of biopsies with a diagnosis of cutaneous Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC), or melanoma (including in situ disease) in which the pathologist communicates results to the clinician within 7 days from the time when the tissue specimen was received by the pathologist.
  • Melanoma: Continuity of Care – Recall System (Quality ID: 137) – Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered, at least once within a 12-month period, into a recall system that includes: A target date for the next complete physical skin exam, AND a process to follow up with patients who either did not make an appointment within the specified timeframe or who missed a scheduled appointment.

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