QPP SURS Newsletter March 2020


  1. Upcoming Events
  2. Small Practice Spotlight: Vaught Eye Associates, SC
  3. CMS Implementing Additional Extreme and Uncontrollable Circumstances Policy Exceptions and Extensions for Upcoming Data Submission Deadlines
  4. January LAN Q&A
  5. Preparing Your EHR for the 2020 Promoting Interoperability Category
  6. Tips for Participating in MIPS Using a Registry
  7. Monthly Observance: Brain Injury Awareness Month

Upcoming Events

Doctor Talking to Patient


*There will be no March and April 2020 LAN Webinars

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

*Dates and times to be announced

Additional Upcoming Events and Links to Past Events

Small Practice Spotlight: Vaught Eye Associates, SC

Collette Wineglass, Insurance and Billing Manager

Vaught Eye Associates is a small ophthalmology and optometry practice in Conway, South Carolina. The practice includes three MIPS-eligible clinicians who chose to report as a group and achieved high scores in both 2017 and 2018. According to Collette Wineglass, the practice’s Insurance and Billing Manager, the practice’s success with MIPS was due to the following factors:

  • Strong relationships and communication – Collette shared that regular and open communication with staff about MIPS was the most important contribution to their practice’s success with MIPS. Her relationships with the entire staff, including scribes, technicians, and providers has greatly facilitated MIPS data collection and reporting because everyone understands their role in the process. Once a month at Vaught Eye Associates weekly manager’s meeting Collette updates the entire practice on their progress on MIPS measures and engages the team to discuss and address any obstacles or problems with data collection. 
  • Integration between the electronic health record (EHR) and registry – Vaught Eye Associates uses Eyefinity EHR software to collect and document patient information. Eyefinity’s MIPS center provides step-by-step instructions on how to collect information for each measure. Because several of the providers are members of the American Academy of Ophthalmology, the practice was able to use the Intelligent Research in Sight (IRIS) registry for MIPS reporting at no additional cost to the practice. The Eyefinity EHR automatically integrates with the IRIS registry, which allows for seamless MIPS reporting.
  • Work with your Technical Assistance Contractor (TAC) – Collette worked closely with the South Carolina Office of Rural Health, a subcontractor to Alliant (its TAC), to understand the practice’s requirements under MIPS. The group helped Collette review the practice’s performance feedback and worked with her in person at her office to discuss the group’s cost category score. As a result, Collette is now working on identifying strategies to reduce the cost of care for their patients. 

Collette’s advice for other small practices working to improve their MIPS score is to take advantage of all the available resources, stay on top of your data collection, and make any necessary changes to fix data collection or documentation issues. Keep these tips in mind as you continue your 2020 MIPS reporting!

CMS Implementing Additional Extreme and Uncontrollable Circumstances Policy Exceptions and Extensions for Upcoming Data Submission Deadlines

To reduce reporting burden during the COVID-19 crisis, CMS has recently announced the following:

  • You now have until April 30, 2020 to submit your 2019 MIPS data.
  • If you don’t submit any MIPS data by April 30, 2020, then you will qualify for the 2019 automatic extreme and uncontrollable circumstance policy and will receive a neutral payment adjustment for the 2021 MIPS payment year.

If you are still able to report 2019 data, please consider submitting MIPS data. Benefits of reporting include:

  • You may be eligible for a positive payment adjustment (if you receive 30 points or more)
  • The ability to track progress year over year
  • Maintain your team’s reporting workflows and habits
  • Position your practice for success in future years

If you have questions about reporting your 2019 MIPS data, do not hesitate to contact your Technical Assistance Contractor. To find your TAC, click here. For more information on what CMS is doing to address the COVID-19 pandemic, see the Current Emergencies page.

January LAN Q&A

The following questions were among those asked by the attendees of the January 2020 LAN webinar, entitled “MIPS Question and Answer Town Hall Event 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. How can we overcome the difficulty of finding specialty measures?

In the 2020 reporting year, there are 46 specialty measure sets that clinicians can choose to submit. In doing so, clinicians must submit data on at least 6 measures within that set. If the set contains fewer than 6 measures, the clinician or practice should submit each measure in the set. To explore the available specialty measure sets, use the Explore Measures Tool on the QPP Website and filter measures by specialty measure set.

If none of the available sets is a good fit for your practice, we recommend consulting the state or national professional association for your specialty. Often these organizations will provide guidance on what measures are relevant.

Finally, you can contact your region’s technical assistance contractor (TAC) for free personalized assistance, including selecting measures. You can find the contact information for your region’s TAC here.

2. If we claim exclusions, does it hinder our ability to score enough points to receive the payments?

Clinicians may claim measure exclusions on select MIPS measures that may be difficult to report based on a practice’s volume of patients, electronic health record technology, or their practice’s specialty. If clinicians claim measure exclusions, CMS will reallocate the points for excluded measures to other measures. 

For more information on measure exclusions in each of the performance categories, see the 2020 Promoting Interoperability Measure Specifications, or the 2020 Clinical Quality Measure Specifications and Supporting Documents or the 2020 Medicare Part B Claims Measure Specifications and Supporting Documents.

3. What is required to avoid a negative payment adjustment?

To avoid receiving a negative payment adjustment, eligible clinicians must achieve the minimum performance threshold of 45 points during the 2020 performance period. This is an increase from the 2019 performance threshold of 30 points. To avoid a negative payment adjustment, consider reporting on as many of the performance categories as possible. Plan to report at least six quality measures (or a complete specialty measure set) and select measures that will be easy for your practice to collect and accurately document. Small practices can receive up to ten points per quality measure and will receive three points for measures that don’t meet data completeness requirements. Additionally, CMS will automatically award six points to small practices who submit at least one quality measure. In the Improvement Activity category, small practices can receive 15 points by reporting one high-weighted activity or two medium-weighted improvement activities. In the Promoting Interoperability performance category, small practices will continue to have the option to apply for a hardship exception to have this category reweighted to zero. Keep these flexibilities in mind as you plan to report for the 2020 performance period.

Preparing Your EHR for the 2020 Promoting Interoperability Category

In 2020, CMS will continue its policy of requiring MIPS-eligible clinicians to use 2015 Edition Certified Electronic Health Record Technology (CEHRT) to report Promoting Interoperability (PI) data. Small practices that do not have 2015 Edition CEHRT may apply for a PI performance category hardship exception.

If you are not planning to seek a hardship exception for the PI category, you must ensure that your EHR is certified to the 2015 Edition. To confirm certification, you can search for your EHR on the Certified Health IT Product List. On this webpage, you can also find your EHR’s CMS Identification code, which you will need to submit along with your data. If you have concerns about the certification status of a specific EHR technology, the website also provides a list of appropriate contacts.

It’s a good idea to begin the process of confirming your EHR certification early in the year. In order to qualify for MIPS, your 2015 Edition functionality must be in place by the first day of your PI performance period, which can be any 90-day continuous period during the performance year. Your EHR must be certified by the last day of the period. You also must use the functionality for the full duration of the reporting period.

While it is not a requirement, many EHRs will allow you to create a MIPS dashboard that can make it easier to monitor your MIPS performance and submit your data. We recommend that you contact your EHR vendor before the start of your PI performance period to see what MIPS tools are available to you and to ensure that they are aware of all certification requirements.

For more information about the PI Category, including measures and reporting methods, visit the CMS QPP website, and check out helpful resources, including the 2020 Promoting Interoperability Performance Category Quick Start Guide. If you are planning on filing for a hardship exception, applications should be available by the summer of 2020. Note that lacking an EHR alone is not enough to qualify you for an exception.

Tips for Participating in MIPS Using a Registry

Are you considering using a registry to report your MIPS data? Check out the following tips and suggestions to see if a registry is right for your practice.

What is a registry?

Clinicians and groups have multiple options for how to collect and submit their MIPS data, including using a Qualified Registry (QR) or Qualified Clinical Data Registry (QCDR) to collect and submit data. QRs and QCDRs are CMS-approved entities that collect clinical data on behalf of clinicians and submit it to CMS for annual MIPS reporting. QRs are limited to the standard MIPS measures, whereas CMS-approved QCDRs typically offer additional measures that are relevant to their specialty. QRs and QCDRs are required to support the Quality performance category, and many also support the Promoting Interoperability and Improvement Activity performance categories. QCDRs may be particularly helpful for specialties that have a limited set of standard MIPS measures from which they can choose. Many specialty societies have created or endorsed their own registries to support their members’ participation in MIPS. Some of these registries can be accessed for free or for a discounted rate for specialty society members.

What are the benefits of a registry?

  • Most registries can submit MIPS data to CMS on your behalf for the Quality, Promoting Interoperability (PI), and Improvement Activities (IA) performance categories.
  • Some registries can automatically pull data from compatible EHRs, saving you time and effort.
  • If you do not have an EHR, some registries will allow you to submit data through a spreadsheet, and then they will submit your MIPS data electronically on your behalf.
  • Some registries will let you submit data retroactively, which may be helpful if you started collecting data later in the performance period.
  • QRs and QCDRs are required to provide MIPS-eligible clinicians with feedback reports at least four times a year on all performance categories that require data submission (this excludes the cost performance category, for which clinicians are not required to submit any data).
  • Using a registry can provide you with the data you need to monitor and take steps to improve care processes.

What should I look for in a registry?

Questions to keep in mind when selecting a QR or QCDR include:

  • How are data entered (e.g., manually, via Excel upload, QRDA file, etc.)? How much time will the data upload take?
  • When are the deadlines for participating and entering data?

CMS recently updated the requirements for QRs and QCDRs to reduce the burden on clinicians and groups. For example, QRs and QCDRs must be able to submit data for all of the MIPS performance categories that require data submission (i.e., Quality, IA, and PI), beginning in 2021. The intent of this requirement is to reduce reporting burden on behalf of clinicians who were previously required to use multiple submission types to report to CMS for purposes of MIPS. For more information on the new guidance, see the 2020 QPP Final Rule – Updates for QCDRs and Registries.

Monthly Observance: Brain Injury Awareness Month

March is Brain Injury Awareness month, and an excellent opportunity to explore ways in which your MIPS participation can overlap with brain injury prevention and treatment.

According to the National Institute of Neurological Disorders and Stroke, a traumatic brain injury (TBI) can be caused by a bump, blow, or jolt to the head, or penetrating head injury, which can lead to short or long-term changes affecting thinking, sensation, language, or emotion. Anyone can be affected by a brain injury, but it is a particular concern for young people and the elderly. According to the Centers for Disease Control and Prevention, TBI-related deaths and hospitalizations are highest for persons 75 years and older compared to other age groups, with falls making up the majority of TBI-related emergency room visits.

There are a broad range of activities and interventions that prevent TBI or support the health of those who have sustained injuries of this kind. MIPS includes a few quality measures focused on appropriately identifying head trauma. Read more about these measures below and consider including them in your reporting to improve care and strengthen your MIPS score:

  • Falls: Risk Assessment (Quality ID 154): Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months.
  • Falls: Plan of Care (Quality ID 155): Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months.
  • Falls: Screening for Future Fall Risk (Quality ID 318): Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period.

If you practice emergency medicine, consider the following MIPS measures:

  • Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years (Quality ID 416): Percentage of emergency department visits for patients aged 2 through 17 years who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the Pediatric Emergency Care Applied Research Network (PECARN) prediction rules for traumatic brain injury.
  • Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older (Quality ID 415): Percentage of emergency department visits for patients aged 18 years and older who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care clinician who have an indication for a head CT.

For more information on these MIPS measures, check out the Explore Measures and Activities tool on the QPP website.

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