QPP SURS Newsletter November 2020


  1. Upcoming Events
  2. Small Practice Spotlight– Spine & Nerve Diagnostic Center
  3. Is Moving to an APM Right for your Practice?
  4. Reminder: 2020 Performance Year Flexibilities
  5. September LAN Q&A: Maximizing your MIPS Score: Advice for Solo and Small Group Practices
  6. What is the Eligibility Measure Applicability (EMA) Process?
  7. Monthly Observance – National Family Health History Month

Upcoming Events

Doctor Talking to Patient


Upcoming Webinar:

December 2020 LAN Webinar: Implications of the Year 5 Final Rule for Solo and Small Group Practices*

* Dates are subject to change based on the release of the Final Rule

Additional Upcoming Events and Links to Past Events

Small Practice Spotlight – Spine & Nerve Diagnostic Center

Dr.  Surekha Reddy is an internal medicine physician and office administrator for Spine & Nerve Diagnostic Center, a small pain management clinic with multiple locations in the greater Sacramento, California area. The providers at Spine & Nerve Diagnostic Center have been participating in MIPS for several years, but had to make adjustments to the clinic’s workflow to continue collecting MIPS measure data in light of the COVID-19 pandemic. Thanks to support from its technical assistance (TA) contractor (HSAG), the practice has been able to continue collecting MIPS measure data during the 2020 performance year. Below are two examples of how Dr. Reddy’s practice has adjusted its MIPS workflows.  

Dr. Reddy’s practice reports on the Body Mass Index (BMI) quality measure (Quality ID 128 – BMI Screening and Follow-up Care Plan). While providers normally record the height and weight of patients during in-office visits, Dr. Reddy shared that the practice now relies on patients participating in telehealth visits to tell providers if their weight has changed, and providers document that change in the medical record, being careful to note that this information is self-reported. This data collection approach allows her practice to continue to get credit for the BMI MIPS quality measure.

Spine & Nerve Diagnostic Center also reports on the Depression Screening quality measure (Quality ID 134 – Screening for Depression and Follow-up Plan). Before the pandemic, patients used to fill out a depression screening questionnaire in the waiting room prior to seeing the provider. Now, during telehealth visits, providers verbally ask the questions in the survey, which Dr. Reddy notes is more time consuming, especially given that the practice must document the information in the medical record on the same day as the office visit. While providers have had to alter their data collection processes, they have continued to successfully gather data for these and other MIPS measures.

Dr. Reddy recommends that small practices start by selecting one or two measures to focus on improving so as not to overwhelm providers with instructions on data collection and documentation. Dr. Reddy strongly recommends reaching out to your regional TA contractor for free customized assistance. Dr. Reddy’s TA contractor has been invaluable for her clinic. She meets with her TA contractor approximately three times a year and particularly values its resources summarizing the year-over-year changes in MIPS. To find your TA contractor, click here.

Is Moving to an APM Right for your Practice?

Alternative Payment Models (APMs) are value-based approaches to payments for patient care that incentivize high quality and cost-efficient care. One of the major goals of the Quality Payment Program (QPP) is to maximize participation in APMs, which hold clinicians financially and clinically accountable for patient care. There are two types of APMs within the QPP:

APM TypeDescription
Merit-Based Incentive Payment System (MIPS) APMsMIPS APMs base payment incentives on overall performance, cost/utilization, and performance on quality measures. Participants in MIPS APMs benefit from streamlined APM reporting and scoring advantages under the APM scoring standard, which can maximize annual positive payment adjustments.
Advanced APMs*Advanced APMs require participants to use Certified Electronic Health Record Technology (CEHRT). Advanced APMs also base Medicare payments on performance on quality measures but require participants to bear more than nominal financial risk. Clinicians who meet thresholds for APM participation become qualifying APM participants (QPs) in Advanced APMs, which exempts them from MIPS reporting and earns clinicians within the APM an annual five percent bonus on their Medicare FFS payments.  
*Some MIPS APMs can also be Advanced APMs

Since the inception of the QPP in 2017, many clinicians have opted to participate in APMs to take advantage of the benefits they provide. In addition to the potential to achieve positive payment adjustments and/or shared savings, APMs offer clinicians the opportunity to improve patient care through such features as enhanced team-based care, standardized processes and workflows, and sharing of best practices and resources.

Here are some questions your practice might ask when deciding whether to participate in an APM:

  • Does my practice meet the minimum criteria for APM participation? CMS provides information about APMs, including basic eligibility criteria, on the QPP website.
  • What APM options are available for my practice? Visit the QPP website for a complete list of 2020 MIPS APMs and Advanced APMs, or see the Innovation Models website for more information about specific Advanced APM models.
  • What is the size and scope of the APM I might consider? Consider how many practices or clinicians are included in the APM, the size of the patient base, how long it has been operating, geographic location, and if possible, its performance history.
  • What are the costs to join an APM? Startup costs will vary depending on your practice’s existing resources such as an EHR system. In some cases, the APM organization may handle the cost of technology upgrades, but in other cases, financial responsibility may fall to APM participants.
  • What staffing and time resources would be required? It is important to know your responsibilities within the APM, such as any new processes that your practice would need to put into place, and what your reporting requirements would be. You’ll want to consider what resources are required to participate in an APM, how staff roles and work flows would change, and make a plan for implementing the necessary changes.
  • Am I willing to accept financial risk? Learn about any applicable financial risk for not meeting the quality and cost requirements of the APM you are considering. Additionally, joining an APM means that your payments are tied to the performance of the APM entity as a whole, and Advanced APMs require you to bear downside risk. Ask yourself whether any of these potential risks are feasible for your practice.

CMS is considering making APM participation even easier through a new APM Performance Pathway (APP). This would would reduce the number of measures practices will be required to report. ,. For more information, see the CMS 2021 Quality Payment Program Proposed Rule Overview Fact Sheet.

Ultimately, the choice to move to an APM is unique to the circumstances of your practice. It is important to consider the potential benefits and risks of APM participation. For additional information on considerations for joining an APM, please contact your Technical Assistance (TA) Contractor. You can also review the September 2019 LAN webinar on this topic. 

Reminder: 2020 Performance Year Flexibilities

As the 2020 performance year comes to a close, it is important to keep in mind the flexibilities that the Centers for Medicare & Medicare Services (CMS) has provided for solo and small group practices. See below for a summary of flexibilities in the Quality Payment Program in response to the COVID-19 pandemic public health emergency.

  • Clinicians, group practices, and virtual groups can apply for the Extreme and Uncontrollable Circumstances (EUC) Exception if the pandemic is preventing collection of MIPS measure data for an extended period of time, or if the pandemic could impact performance on cost measures. If approved, this exception reweights one or more Merit-Incentive Based Payment System (MIPS) performance categories to 0%. For more information, see the 2020 Quality Payment Program Exception Applications Fact Sheet.
  • Clinicians, group practice, and virtual groups can receive MIPS credit for caring for patients with COVID-19 by participating in the COVID-19 Clinical Trials Improvement Activity. To get credit for this activity, clinicians must attest that they have participated in a COVID-19 clinical trial and report their findings through a clinical data repository or, participate in the care of a patient diagnosed with COVID-19 and submit relevant clinical data to a clinical data registry for ongoing COVID-19 research. 

Furthermore, CMS is proposing the following flexibilities in the Calendar Year 2021 Physician Fee Schedule:

  • Allowing APM Entities to submit an EUC Exception application for reweighting of MIPS performance categories for the 2020 performance year.
  • Revising the Complex Patient Bonus to account for additional complexity in treating patients during the COVID-19 pandemic by allowing clinicians, groups, virtual groups, and APM Entities to earn up to 10 bonus points towards their final score for the 2020 performance year.

The 2021 Physician Fee Schedule rule will be finalized in December 2020. CMS is continuing to explore ways to reduce the burden on clinicians and provide further support for continued participation in MIPS. For more information on the Quality Payment Program COVID-19 Response, click here

September LAN Q&A: Maximizing your MIPS Score: Advice for Solo and Small Group Practices

The following questions were among those asked by the attendees of the September 2020 LAN webinar, entitled “Maximizing Your MIPS Score: Advice for Solo and Small Group Practice.” 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. Can I apply for the Promoting Interoperability (PI) Hardship Exception Application for both individual providers and the group?  Can I still opt out of the PI measure if I am a small practice?

Both individuals and groups may apply for the PI Performance Category Hardship Exception. Please note that if you submit an application on behalf of a group, every office location/practice within the Taxpayer Identification Number (TIN) must experience the hardship for the group to qualify for the PI Hardship Exception. The deadline to submit the PI Hardship Exception application is December 31, 2020, at 8 pm ET. It is recommended that you apply before this date. If your application is not approved, you will need time to submit MIPS data.

MIPS-eligible practices can apply for the Promoting Interoperability Performance Category Hardship Exception for one of the following reasons:

  • You are a small practice (a TIN or virtual group with 15 or fewer eligible clinicians)
  • You have decertified EHR technology
  • You have insufficient Internet connectivity
  • You face extreme and uncontrollable circumstances such as disaster, practice closure, severe financial distress, or vendor issues
  • You lack control over the availability of CEHRT

Lacking CEHRT does not qualify you for re-weighting. If your practice is approved and receives a PI Exception, your PI score will be reweighted from 25% to 0% of your overall MIPS score, and your Quality score will be reweighted from 45% to 70% of your overall score.

Please see the 2020 Quality Payment Program (QPP) Exception Applications Fact Sheet for a quick overview of each exception application, frequently asked questions, and additional appendices discussing category weighting and the automatic reweighting process.

2. What should I do if I have applied for the Hardship Exception due to COVID-19 and still have not received a response?

There is currently no information available about when practices should expect final decisions for hardship exception applications. You will be notified by email if your request was approved or denied. You will also be able to check the status of your application by signing into the QPP website. If your application is approved, you will see your exception in your eligibility profile in the QPP Participation Status Tool. (This may not be visible until the 2021 submission window begins.) If you are concerned there may be an issue with your application, you can call the QPP Help Desk at 1-866-288-8292 to check the status of your application. If your application is ultimately rejected, you will be expected to report MIPS data. For that reason, we recommend that you continue to collect whatever data you can.

3. How does reporting work if we do not have electronic medical records?

Practices without EHRs can successfully participate in MIPS and are not exempt from participation because they do not have an EHR. MIPS data can be reported in four ways: 1) Medicare Part B claims (only available for practices with 15 or fewer clinicians); 2) Sign in and upload data onto the QPP website as a QRDA3 file; 3) Use the CMS Web Interface to manually enter data*; or 4) Direct Submission with the CMS Web Interface API*. If you do not have an EHR system, you will likely want to pursue options 1 or 3.

Note that you cannot participate in the Promoting Interoperability category without CEHRT. You should consider applying for a PI Hardship Exception if you are eligible. See question 1 above or the 2020 QPP Exception Application Fact Sheet for more details.

If this is your first time participating in MIPS, we strongly recommend you reach out to your regional TA Contractor for free personalized guidance and help setting up a plan for collecting and submitting data. Many considerations are relevant to how your practice might collect and report data and your TA contractor will be able to explore these topics in depth. You may also want to refer to the 2020 Reporting MIPS Quality Measures through Part B Claims Quick Start Guide and the 2020 MIPS Quick Start Guide.

*Note: The CMS Web Interface API is being phased out in 2021.

What is the Eligibility Measure Applicability (EMA) Process?

To receive points in the Quality performance category, MIPS-eligible clinicians and groups are generally required to submit six quality measures. One of the quality measures should be an outcome measure (outcome measures show how a healthcare service or intervention affects patients’ health status); however, if no outcome measure is available­­, a high priority measure [1]should be reported. In recognition of the fact that some specialists may not be able to identify six clinically relevant quality measures to report, 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.

When a clinician or group submits fewer than six measures or does not submit an outcome or high-priority measure, CMS will use the Eligibility Measure Applicability (EMA) process to determine if the clinician or group could have submitted additional clinically relevant quality measures. The EMA process is also used to adjust scoring to reflect the number of clinically relevant measures.

The EMA process applies to:

  • Small practices that submit MIPS quality measures through Medicare Part B claims; and
  • Any MIPS clinician working with a third-party intermediary to collect and submit MIPS Clinical Quality Measures (CQMs)

The EMA process has two steps:

  • Step 1: CMS determines whether there are additional measures that are clinically related to the quality measures the clinician did submit. CMS also determines whether there were any clinically relevant outcome or high priority measures that could have been reported. Keep in mind that if you submit the full specialty measure set, EMA won’t apply to you.
  • Step 2: CMS determines whether the clinician met the minimum threshold test by verifying that at least 20 denominator-eligible cases exist for identified measures.

If CMS finds that a clinician or group submitted all of the clinically relevant quality measures possible, the clinician can receive full points in the Quality performance category. If CMS does identify additional relevant quality measures, but there were fewer than 20 eligible cases for that measure, the clinician can still receive full points in the Quality performance category. However, if CMS does find additional measures that could have been reported that meet the minimum case threshold, the clinician will receive zero measure achievement points for each missing measure.

If you are reporting MIPS measures via claims or Qualified Registry (QR) and cannot find six relevant measures to report, your first step should be to find your CMS Specialty Measure Set in the Explore Measures & Activities tool on the QPP website to verify which measures CMS considers clinically relevant for your specialty. You can also use the Single Source file found in the measure specifications and supporting documents zip file for your submission method (see links below). Single Source files enable you to enter your common billing codes and find relevant MIPS measures to report:

If you would like personalized assistance, we recommend reaching out to your regional Technical Assistance (TA) Contractor for assistance. You can also check out the CMS EMA Process Resources, as well as QSource’s helpful guide to the EMA Process.

[1] MIPS scoring policies emphasize and focus on high priority measures that impact beneficiaries. High-priority measures are not an additional measure type, but fall within these measure categories: Outcome (includes intermediateoutcome and patient-reported); appropriate use; patient engagement/experience;  patient safety;  efficiency measures;  care coordination; and opioid-related

Monthly Observance – National Family Health History Month

November is National Family Health History Month in the United States, a national campaign to encourage people in the U.S. to learn about their family’s health history. Many people know about their relatives’ health histories, but few take proactive steps to get screened for diseases and conditions for which they may be at increased risk. November is an excellent opportunity for you to talk to your patients about their family medical history and what screening and preventive measures are appropriate for them.

You can also recommend that your patients prepare for their upcoming appointments by filling out the My Family Health Portrait online tool from the U.S. Surgeon General, which walks through the steps of assembling a personal family health history. Furthermore, reporting on MIPS measures related to chronic diseases and preventive screenings could help your patients identify their risk for genetic conditions. Relevant MIPS measures include:

  • Breast Cancer Screening (Quality ID: 112) – Percentage of women 50 – 74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the measurement period.
  • Colorectal Cancer Screening (Quality ID: 113) – Percentage of patients 50-75 years of age who had appropriate screening for colorectal cancer.
  • Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented (Quality ID: 317) – Percentage of patients aged 18 years and older seen during the submitting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.
  • Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan (Quality ID: 128) – Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter.

For more information on National Family Health History Month, click here.

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