QPP SURS Newsletter September 2019

QPP SURS Quality Payment Program


Upcoming Events

Doctor Talking to Patient


September 2019 LAN Webinar: Considerations for Joining an APM for Solo and Small Group Practices

October 2019 LAN Webinar: How to Transform your Practice Workflow to Succeed in MIPS: Advice for Solo and Small Group Practices

Additional Upcoming Events and Links to Past Events

Past QPP SURS events: https://qppsurs.com/webinar-resources/

Small Practice Spotlight: Pulmonary Sleep & Critical Care Specialists

Pulmonary, Sleep & Critical Care Specialists is a small practice in Port Charlotte, Florida.  The practice consists of 5 MIPS-eligible clinicians, all of whom received final scores of 100 in 2018! How did this pulmonology practice achieve such exceptional scores? Linda Mckenna, the Practice Manager, noted the following strategies as being the key to their success with MIPS and the Quality Payment Program:

  • The Practice Manager is the Facilitator and Educator for designated key Point Persons. The Practice Manager is responsible for staying up to date on the Quality Payment Program.  For example, Linda stays up to date on the latest CMS announcements and Medicare Part B news bulletins and shares the details with the key Point Persons.
  • Know your Measures! Explore your measures in the EHR and how the information flows into the patient’s chart.  What part of the patients chart contains the MIPS measures? Linda’s office measures Asthma Care, BMI, Documentation of Medication, Access to Health Information and Screening for Tobacco to name a few.
  • Designate the appropriate key Point Person. Multiple Point Persons are needed because the measures are all unique to the patient visit and experience says Linda. Their office includes the Nursing Supervisor, who periodically reviews the patient chart for completion, and the Facility Manager, who periodically reviews the system reports for performance status in addition to making sure the EHR is operating on the most recent version.
  • Hold quarterly staff meetings to include MIPS performance.
  • Take advantage of the electronic health record (EHR) to monitor MIPS Measures. Their office contracted with Athena because it had the best platform at the time for the size of their practice.  Athena also has a dashboard which includes the MIPS calculator that shows the practice scores on their selected MIPS Measures.  When monitored monthly it allows for the Facility Manager to swing around to appropriate Point Persons and share the information for immediate action.
  • Engage staff in MIPS by making reporting fun! It should always be the Facilitator’s obligation to make the process fun and easy for everyone.  Linda explained that in her group practice communication is vital to their success and found that with the use of Visual Aids, such as Memory Boards strategically placed in the Staff Lunch Room, was the best mechanism for them. For example, she designed a funny memory board using actor/former football player, Michael Strahan’s, photo with the title “Got Gap” which highlights the definition of Risk Scores and Gaps in Risk Scores. She also included a board with a photo of Rapper Jay Z smoking a cigar to emphasize the requirement of reporting smoking history whenever a patient presents with Asthma or COPD.  Lastly, Linda lightens up the end of the day by texting the physicians which one of them successfully remembered to consistently report smoking history.  This is always fun because her physicians are very competitive and really enjoy the competition.

Pulmonary, Sleep & Critical Care Specialists still struggle with certain MIPS requirements, especially patient engagement in online portals since they are located in an area with a lot of retirees.  However, the practice was still a standout success over the past two performance periods due to the full engagement of their practice in MIPS and the leveraging of their EHR to help with tracking their measures.  Consider adopting some of their tips to engage your office in MIPS Reporting!

2019 Hardship Application Process Now Open!

Quality Payment Program (QPP) Exception Applications are now available on the QPP website. This includes applications for the Promoting Interoperability (PI) Hardship Exception and the Extreme and Uncontrollable Circumstances Hardship Exception. Applications must be submitted by December 31, 2019 in order for CMS to reweight your performance category scores as applicable. For more information and to find out if you qualify for these exceptions, see the QPP Hardship Exception page on the QPP website.

Reminder: Start your 90-day Performance Period by October 3, 2019!

MIPS requires eligible clinicians to report measure data for the Promoting Interoperability (PI) and Improvement Activities (IA) performance categories for 90 continuous days or more during 2019.  Keep in mind thatOctober 3, 2019 is the last day to begin collecting data collection in order to meet this 90-continuous day requirement for the 2019 performance period. For tips on how to successfully report on these two categories, see the 2019 PI Performance Category Fact Sheet and/or 2019 PI Guide, or the 2019 IA Performance Category Fact Sheet and/or the 2019 Improvement Activities Guide. If you have further questions, reach out to your Technical Assistance Contractor by clicking here.

FAQs on Completing the Security Risk Analysis

The Security Risk Analysis (SRA) is a prerequisite for participation in the MIPS Promoting Interoperability (PI) performance category. This requirement can be daunting for small practices who do not always have time or resources to conduct an SRA. With the right information and appropriate planning, conducting your SRA can be a straightforward and beneficial process. Here are answers to some common SRA questions to help get you started:

Why do I have to conduct an SRA?

The objective of the SRA requirement is to protect all patient health information, particularly electronic patient health information (ePHI).

When should I conduct my SRA?

You must conduct or review an SRA on an annual basis. You should conduct a full SRA if you have not done so previously, or if you have implemented a new EHR system. Otherwise you can instead review and update the prior analysis for changes in risks. You do not have to conduct your SRA during your MIPS 90-day performance period, but you must complete an analysis within the same calendar year of the performance period. It is likely that your first SRA will take longer than subsequent SRAs in later performance years.

What are the requirements?

MIPS requires that you conduct or review an SRA in accordance with the HIPAA Security Rule. The rule requires you to conduct an accurate and thorough analysis of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of ePHI, including data encryption. You must implement security updates as necessary and correct any security deficiencies that you identify. Please note that you do not need to complete all security updates and corrections immediately. Instead, develop and follow a plan to complete the updates and corrections.

What is the best strategy to complete my SRA?

There is no one correct way to conduct your SRA, and the best strategy for you will vary based on your practice’s needs. A common piece of advice for all practices is to develop a clear strategy before beginning your assessment. You may also consider separating your assessment and correction of security deficiencies into two distinct phases. A good place to start is with the Office of the National Coordinator for Health Information Technology and the HHS Office for Civil Rights’ Security Risk Assessment Tool, which was developed specifically for small and medium practices.

Where can I find more information?

To learn more about SRAs, visit CMS’ description of the measure here and clicking on “2019 MIPS PI Measures Security Risk Analysis.” For a more in-depth explanation of the SRA process, view Telligen’s QPP Resource Center presentation on the subject here. To understand how the SRA requirement fits into the PI performance category and MIPS as a whole, read about the 2019 PI requirements here.

MIPS Quality Measure Spotlight: Influenza Immunization

In preparation for the 2019-2020 flu season, many clinicians have chosen to report on the Preventive Care and Screening: Influenza Immunization MIPS quality measure (Quality ID: 110). This measure tracks the percentage of patients 6 months and older who were seen for a visit between October 1 and March 31 of the current flu season and received an influenza immunization OR who reported previous receipt of an influenza immunization. To help improve your score on this quality measure in 2020, consider the following tips.

  • Immunizations that are administered in August and September 2019 can be documented for MIPS when the patient visits the office during flu season (October 1, 2019-March 31, 2020).
  • Keep in mind that when a patient declines the influenza vaccine, the reason why must be documented to receive full credit for the measure.
  • Try to get access to data from other facilities where patients receive vaccines (Minute Clinic, county health departments, etc.) and incorporate that into the patient’s chart.

For more information on the Influenza Immunization quality measure, see the Explore Measures Tool on the QPP website. For more information about how to prepare your practice for flu season, see the CDC’s Fight Flu Toolkit.

New MIPS Data Validation and Audits

The Centers for Medicare & Medicaid Services (CMS) recently announced that it has contracted with Guidehouse to conduct MIPS data validation and audits (DVAs) for the 2017 and 2018 performance years. Practices will be selected randomly for DVA. The Quality, Improvement Activities, and Promoting Interoperability categories can be audited, but practices will not necessarily be audited on every category. If your practice is selected for a DVA, bear in mind that you will have 45 calendar days from the date of the notice to provide the requested information. For more information, please review the MIPS Data Validation and Audit Fact Sheet.

The following DVA resources are also available on the Quality Payment Program Resource Library:

Monthly Observance: Childhood Obesity Month

September is National Childhood Obesity Month, and an opportunity for you to improve your MIPS score by engaging pediatric patients in making healthy lifestyle choices.

According to the CDC, in the United States, 18.5% of children and adolescents are obese, and certain groups, such as Hispanic and non-Hispanic black populations, are particularly impacted. [1] Obesity puts children at risk for a range of diseases and can lead to health problems later in life.

The good news is that health professionals and families can work together to create opportunities for kids to eat healthier and get more active. The MIPS measures list includes a long-standing measure that addresses weight assessments and nutrition for pediatric patients:

Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents (Quality ID 239): Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period: Three rates are reported:

  • Percentage of patients with height, weight, and body mass index (BMI) percentile documentation
  • Percentage of patients with counseling for nutrition
  • Percentage of patients with counseling for physical activity

If this measure is relevant for your practice, consider reporting it as part of your MIPS quality performance category submission to help reduce the prevalence of childhood obesity in your community.


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