QPP SURS Newsletter October 2020


  1. Upcoming Events
  2. How to Avoid the MIPS Penalty in 2020
  3. Unable to Access the QPP Website?
  4. Maintaining MIPS Momentum
  5. MIPS Measures & Activities for Upcoming Flu Season
  6. Specialist Spotlight: MIPS and Oncology in the COVID-19 Era
  7. Monthly Observance – Health Literacy 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

Additional Upcoming Events and Links to Past Events

How to Avoid the MIPS Penalty in 2020

In the 2020 performance year, MIPS participants need to obtain a minimum of 45 points to prevent a negative payment adjustment in 2022. If you can collect data on one or more MIPS performance categories, there are strategies to help you reach the MIPS performance threshold. Several technical assistance (TA) contractors, including Comagine, Quality Insights, and QSource, have developed free resources to help small practices meet the 2020 performance threshold:

Quality Performance Category

  • Select measures from the 2020 Quality Measure List for which your practice can meet the data completeness requirements or measures for which you can obtain data from 70 percent of eligible patients. Consider selecting high-weighted and/or outcome measures to obtain as many points as possible.
  • Review your 2019 performance feedback and note which measures were successful for your practice and which need improvement.
  • Review your specialty measure set and report on six measures in the set. If the set contains fewer than six measures, report on all measures in the set.
  • If possible, consider reporting on MIPS measures that can be collected via telehealth due to the possibility of a decrease in the number of in-person office visits this fall and winter.
  • Consider using multiple submission methods if you cannot find relevant measures. For example, registries may offer additional MIPS measures to report.

Remember that clinicians in small practices (15 or fewer clinicians) automatically receive six points in the quality category if at least one quality measure is reported.

Cost Performance Category

  • You do not need to report any data for the Cost performance category. CMS automatically calculates your cost score based on administrative claims submitted for the entire calendar year.
  • Review your performance feedback from previous years, as well as the 2019 Cost Performance Category Fact Sheet, to help understand your past performance.
  • Review the 2020 MIPS Summary of Cost Measures and required case minimums to see which cost measures will be scored.
  • Identify your most costly patients and consider taking steps to improve care coordination for these patients.

Promoting Interoperability (PI) Performance Category

  • Some clinician types qualify for automatic re-weighting of the PI category. See if you qualify using the QPP participation status look-up tool.
  • If you are a small practice and have insufficient internet connectivity, decertified EHR technology, or lack of control over the availability of certified EHR technology, you can apply for a PI hardship exception. You can also apply if you face extreme and uncontrollable circumstances, such as practice closure, or severe financial distress. Applications must be submitted by December 31, 2020.

Improvement Activities Performance Category

  • Review the complete list of improvement activities and select activities that make the most sense for your practice. Remember to take credit for any activities that you are already doing as part of your current workflow.
  • Be sure to review which activities are still available and which have been removed for this performance year.
  • Small practices can receive full credit for the Improvement Activities performance category when they complete one high-weighted activity or two medium-weighted activities.

As the COVID-19 pandemic continues, small practices may be struggling to reach the 45-point threshold. If you have been severely impacted by the COVID-19 pandemic or other extreme and uncontrollable circumstances, keep in mind that you can apply for an Extreme and Uncontrollable Circumstances Exception. If approved, this exception will re-weight any or all performance categories to help you avoid a negative payment adjustment.

For more information and advice on how to reach 45 points, contact your TA contractor. To find your TA contractor, click here.

Upgrades to QPP Website May Impact Access

This fall, CMS is applying a network security update to the Quality Payment Program (QPP) website (qpp.cms.gov). If your web browser is outdated, you may no longer be able to access the QPP website. For directions on how to update your browser, see the CMS 2020 Network Security Update Fact Sheet.  If you have further questions, do not hesitate to contact your regional technical assistance (TA) Contractor for free individualized assistance. Find your TA Contractor here. You can also contact the Quality Payment Program at 1-866-288-8292, Monday through Friday, 8:00 a.m. – 8:00 p.m. EST  or email QPP@cms.hhs.gov.

Maintaining MIPS Momentum

The COVID-19 public health emergency has led many clinicians and practices to redefine priorities, modify procedures, and reallocate resources. While it can be challenging to focus on MIPS during this time of unprecedented uncertainty, continuing to collect and report MIPS data could provide long-term benefits for your practice. Below are some reasons why you should keep the momentum going.

  • CMS has proposed to set the performance threshold to 50 points for PY 2021, a 5-point increase from PY 2020. Looking ahead to PY 2021 and beyond, maintaining your team’s reporting workflows and habits will make future reporting easier. Continuing to focus on collecting data now will help your practice in the future as MIPS requirements evolve.
  • The Extreme and Uncontrollable Circumstances policy may become less universally applicable as policymakers and clinicians adapt to the post-pandemic world. If such a decision is made, this would mean that many practices will be required to report MIPS data in PY 2021 and will need to perform at a higher level than has been required in the past to avoid a penalty. Your practice will be better positioned for success if you don’t have to re-learn and re-implement the processes and workflows needed to collect and report MIPS data.
  • CMS is continuing its gradual implementation of the MIPS Value Pathways (MVPs), beginning as early as 2022. With the MVP framework, CMS intends to align and connect measures and activities across the four MIPS performance categories for different specialties or conditions. While CMS envisions that MVPs will ultimately reduce the MIPS reporting burden, clinicians must be prepared to collect and submit the required data for MVP measures. Because MVPs will build on current MIPS measures, staying current with MIPS reporting that is relevant to your practice area or specialty will position your practice to make a more seamless transition to this new framework.

Remember that if you do report data for PY 2020 and receive a final score above 45 points, you may receive a positive payment adjustment in 2022. You can build upon your success in previous years by reviewing your PY 2019 performance results and understanding your areas of strength and weakness.

For the 2020 performance year (PY), CMS is using the Extreme and Uncontrollable Circumstances (EUC) policy to allow clinicians and groups who have been affected by the COVID-19 pandemic to request reweighting of any or all performance categories. For more information on the Quality Payment Program COVID-19 Response, click here. If a practice was prevented from collecting MIPS measures data for an extended period, requesting the EUC exception may be the best option to avoid a penalty.

If you have any questions about your PY 2019 performance feedback, or about MVPs, do not hesitate to contact your TA contractor. To find your TA contractor, click here. For additional information on MVPs, see the MVPs Overview Fact Sheet from CMS.

MIPS Measures & Activities for Upcoming Flu Season

In the United States, the annual influenza season typically starts in the fall and lasts through the winter and early spring. The Centers for Disease Control and Prevention (CDC) recommends the period between early September and late October as the most effective time to get a flu vaccine. The flu is a serious health risk every year, with an average of 8% of the population infected annually. This year, the ongoing COVID-19 pandemic may underscore the importance of vaccination and other influenza prevention measures, as both viruses will be circulating at the same time.

Unfortunately, COVID-19 has resulted in declines in outpatient visits leading to lower than usual vaccination rates. Clinicians should communicate about the benefits of the flu vaccine with their patients of all ages to ensure that they are getting vaccinated against influenza when appropriate.

Consider reporting on the MIPS measure below to boost your MIPS score and help your patients stay healthy this season.

  • Preventive Care and Screening: Influenza Immunization (Quality ID: 110) – Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization.

Keep in mind that immunizations that are administered in August and September 2020 can be documented for MIPS when the patient visits the office during flu season (October 1, 2020-March 31, 2021). Additionally, when a patient declines the influenza vaccine, the reason why must be documented to receive full credit for the measure. Keep these tips in mind as you prepare your patients for the upcoming flu season.

Specialist Spotlight: MIPS and Oncology in the COVID-19 Era

Cancer patients need timely treatment, but in-person visits can be risky for these often immunocompromised patients. To balance the needs of timeliness and COVID-19 prevention, many oncology practices are now delivering a wider range of services through telehealth. This rapid shift was made possible, in part, by CMS’s expansion of telehealth-eligible services, clinician types, communication modes, and originating sites in response to the COVID-19 public health emergency.

If your practice is now offering a wider range of telehealth services, take a moment to review your MIPS measures, and answer the following questions:

  • Will any of your MIPS measure scores likely go down because people are forgoing visits that can only be delivered in person? If so, you may need to consider reporting on new measures.
  • Could you get credit for services delivered via telehealth? For example, telehealth radiation treatment management is now a billable telehealth service. During these tele-visits, you can earn MIPS points by delivering care consistent with these quality measures:
  • Oncology: Medical and Radiation – Pain Intensity Quantified (Quality ID: 143)

Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified.

  • Oncology: Medical and Radiation – Plan of Care for Moderate to Severe Pain (Quality ID: 144) Percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain.
  • If you ask your patients about their medications or advance care planning, you could also earn credit towards the following measures and activities collected via telehealth:
  • Documentation of current medications in the medical record (Quality ID: 130) Percentage of visits for patients aged 18 years and older for which the MIPS-eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counter medications, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency, and route of administration.
  • Advance care plan or surrogate decision-maker documented in the medical record (Quality ID: 047) Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
  • Advance Care Planning (Improvement Activity: IA_PM_21) Implementation of practices/processes to develop advance care planning that includes: documenting the advance care plan or living will within the medical record, educating clinicians about advance care planning motivating them to address advance care planning needs of their patients, and how these needs can translate into quality improvement, educating clinicians on approaches and barriers to talking to patients about end-of-life and palliative care needs and ways to manage its documentation, as well as informing clinicians of the healthcare policy side of advance care planning.

Regardless of which MIPS measures you select, it is important to work with your electronic health record (EHR) vendor to make sure you receive MIPS credit for services provided via telehealth and accurately document measure data. For a list of all 2020 MIPS measures and activities, visit the Explore Measures and Activities section of the QPP website. To review the list of new telehealth services covered by CMS, click here. For a summary of cancer care transformation during the COVID-19 public health emergency, click here.

Monthly Observance – Health Literacy Month

October is Health Literacy Month in the United States, a month dedicated to making health information easier to understand for patients. Misleading or difficult to understand health information can be harmful to individuals and communities. At this time of heightened health risk, clear and accurate health information is particularly important.

There’s no right or wrong way for your practice to get involved in Health Literacy Month, as long as you are working towards making health information more clear and accessible for your patients. There are several MIPS measures and activities you can use to encourage health literacy by rewarding physicians for talking to their patients about health risks, including tobacco use, alcohol or drug dependence, as well as the importance of preventive screenings and periodic assessments of depression and mental health status. MIPS also rewards clinicians for engaging patients in their health information by providing access to patient portals and personal health records. For a list of all available MIPS measures and activities, check out the Explore Measures and Activities tool on the QPP website.

The theme of this year’s Health Literacy Month is “Health Literacy Heroes.” You can visit healthliteracymonth.org to nominate a Health Literacy Hero in your community or read about heroes that others have nominated. The website also includes resources for encouraging health literacy at your practice, including a Health Literacy Handbook. Health literacy is an important part of healthcare, and this month is a great opportunity for you to incorporate it further into your practice.

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