QPP SURS Newsletter September 2020


  1. Upcoming Events
  2. Small Practice Spotlight – Gila Health Resources
  3. Last call to collect Promoting Interoperability and Improvement Activities!
  4. July LAN Q&A: Maximizing Performance in the Promoting Interoperability Category
  5. 2019 MIPS Performance Feedback Resources
  6. Professional Association Resources for Specialists
  7. Monthly Observance – National Preparedness Month

Upcoming Events

Doctor Talking to Patient


Upcoming Webinar:

December 2020 LAN Webinar: Topic is TBD
Registration is forthcoming

Additional Upcoming Events and Links to Past Events

Small Practice Spotlight – Professional Medical Associates

Dr. Naomi Clancy is a family medicine and urgent care doctor who practices in Morenci, a rural town in southeastern Arizona. Dr. Clancy is the Associate Medical Director of Family Medicine at Gila Health Resources, which provides primary care to the town of approximately 1,400 residents. On May 15, 2020, Dr. Clancy shared strategies on how her practice transformed as a result of COVID-19 during a weekly town hall webinar held by the American Academy of Family Physicians (AAFP). A summary of Dr. Clancy’s experience responding to the pandemic and tips for other rural practices is provided below.

1) Establish a disaster plan to prepare your practice for an infectious disease outbreak. Dr. Clancy’s practice developed a disaster plan, which included establishing an outdoor triage tent and an isolation unit. The practice also offers yearly training for all clinical staff on how to properly and effectively put on and remove full Personal Protective Equipment (PPE), which helped prepare the practice for the COVID-19 pandemic.

2) Plan for early and consistent communication with local employers, school districts, and other stakeholders. Dr. Clancy credits her community’s early response to COVID-19, especially actions taken by employers in her community, with limiting the spread of the virus. The Morenci area is home to one of the largest copper mines in the country. The mine owns the majority of public facilities in Morenci, such as the fitness center and library, these facilities were closed three weeks before Arizona’s statewide closure, reducing public exposure. Dr. Clancy noted that the practice’s biggest advantage was its supply of PPE. When the U.S. Food and Drug Administration (FDA) put in emergency use authorization for health care facilities to use PPE certified by the National Institute of Occupational Safety and Health (NIOSH), the mine offered Gila Health Resources access to their NIOSH-certified PPE, helping to keep their providers safe while treating patients in the community.  

3) Modify your practice to keep sick patients separate from well patients. In response to COVID-19, Gila Health Resources separated their building into sick and well sections to limit the potential spread of the virus. Providers began to see patients in the parking lot donning full PPE and conducting “no touch evaluations at car side.” Very few of the providers at Gila Health Resources had ever used telemedicine before the pandemic, but had access to a telehealth platform (Microsoft Teams 365), which sends patients a HIPAA-compliant link to start a video visit. If the patient can’t access Microsoft Teams, they use Doxy.me, Facetime, or Doximity Dialer. Gila Health Resources used the available platforms to conduct telehealth visits.

To hear more details on Dr. Clancy’s experience preparing her practice for COVID-19, click here. If you have questions on how to modify your practice in light of the pandemic, reach out to your Technical Assistance (TA) Contractor. To find your TA Contractor, click here.

Last call to collect Promoting Interoperability and Improvement Activities!

If you are eligible for MIPS in 2020, you are generally required to report on measures and activities in the Promoting Interoperability (PI) and Improvement Activities (IA) performance categories (check your MIPS eligibility here). Both categories require that you collect and report data for a continuous 90-day period during 2020. The last continuous 90-day performance period is rapidly approaching and begins on October 3, 2020.

It is important to understand the specific reporting requirements for each of these categories. Key considerations for the PI performance category include:

  • In certain cases, the PI performance category can be reweighted to 0% of your final score. You may be exempt from having to submit data in this category if:
    • You are an excluded clinician type or have a special status (you or more than 75% of your group or virtual group is ambulatory surgical center-based, hospital-based, or non-patient facing); or
  • Keep in mind that if you submit any PI performance category data, you will be scored on this performance category, even if you qualify for reweighting.
  • If you report data for this performance category, you must meet Certified Electronic Health Record Technology (CEHRT) requirements for 2020. This means that you must:
    • Have 2015 edition CEHRT functionality in place by the first day of your Promoting Interoperability performance period;
    • Have your EHR certified by the Office of the National Coordinator for Health Information Technology (ONC) to the 2015 Edition CEHRT criteria by the last day of your performance period;
    • Conduct or review a security risk analysis on your 2015 Edition CEHRT functionality on an annual basis, within the calendar year of the performance period.

Key considerations for the IA performance category include:

  • After selecting improvement activities, you must perform each activity for at least one continuous 90-day period in 2020. Activities do not have to be performed concurrently.
  • If you’re reporting as a group or virtual group, at least 50% of the clinicians in the group must perform the activity for the group to attest and receive credit for that activity. Individual clinicians within the group can perform the same activity during different continuous 90-day periods.

For assistance understanding your reporting requirements for the PI and IA performance categories, see the 2020 Promoting Interoperability Performance Category Quick Start Guide and the 2020 Improvement Activities Performance Category Quick Start Guide. If you have additional questions, do not hesitate to contact your Technical Assistance (TA) Contractor. To find your TA Contractor, click here.

July LAN Q&A: Maximizing Performance in the Promoting Interoperability Category

The following questions were among those asked by the attendees of the July 2020 LAN webinar, entitled “Maximizing Your Performance in the Promoting Interoperability Category 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 you explain the Promoting Interoperability (PI) exception?

Under the Merit-based Incentive Payment System (MIPS), you may qualify for re-weighting of the PI performance category (to 0%) if you meet certain criteria. MIPS-eligible clinicians, groups, and virtual groups may submit a MIPS Promoting Interoperability Performance Category Hardship Exception Application citing one of the following specified reasons:

  • You’re a small practice
  • 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 Certified Electronic Health Record Technology (CEHRT)

Beginning this year, you will need an HCQIS Access Roles and Profile (HARP) account to submit a MIPS PI Performance Category Hardship Exception Application. Please note that even if your application is accepted, you will still be able to submit PI data. Read more about the exceptions process here.

2) Is the hardship exception available for small practices for the 2020 Performance Year?

Yes, the application window is open now through December 31, 2020, 8:00 pm ET. Both the Extreme and Uncontrollable Circumstances Exception (EUC) and the MIPS PI Performance Category Hardship Exception are available. The Extreme and Uncontrollable Circumstances Exception application allows you to request reweighting for any or all performance categories if you encounter an extreme and uncontrollable circumstance or public health emergency, such as COVID-19, that is outside of your control. Information is not currently available about when application decisions will be available. If your application is not approved, your practice will still be required to submit data, so you should continue to collect data if you are able.

3) As a primary care provider, how do we close the referral loop if our practice is not receiving patients at this time? 

Any MIPS-eligible clinician who transfers a patient to another setting or refers a patient fewer than 100 times during the performance period may claim an exclusion from the Support Electronic Referral Loops by selecting the Sending Health Information measure. Additionally, any MIPS-eligible clinician who receives referrals (also known as a transition of care) or has less than 100 patient encounters during the performance period may claim an exclusion from the Support Electronic Referral Loops by selecting the Receiving Health Information measure.

If you do not believe your practice meets these criteria, but you are still concerned about your ability to meet these requirements, you may consider applying for either the Extreme and Uncontrollable Circumstances Exception or the MIPS PI Performance Category Hardship Exception. See Question 2 above for more details.

2019 MIPS Performance Feedback Resources

In August 2020, providers who participated in MIPS during the 2019 performance period received their performance feedback. To access your performance feedback, go to qpp.cms.gov and sign in to your HCQIS Authorized Roles and Profile (HARP) account. If you need more information on how to set up or access your HARP account, see the QPP User Access Guide.

To help clinicians process their feedback, CMS published a number of new resources on the QPP website, including:

In the above links, you can find answers to frequently asked questions, information on patient-level data reports, as well as steps on how to submit a targeted review application if you find an error in your 2019 MIPS performance feedback. If you would like CMS to review their calculation of your MIPS score, you have until October 5, 2020, to submit a targeted review application. Keep in mind that you can complete a targeted review application through your HARP account. If you have further questions about your performance feedback, do not hesitate to reach out to your Technical Assistance (TA) Contractor. Find your TA Contractor here.

Professional Association Resources for Specialists

If you are a specialist struggling to find relevant MIPS measures and activities, remember that your professional specialty society may offer MIPS tools and resources to help you succeed in MIPS. After you review the specialty guides published by CMS on the QPP website, keep in mind that you can also take advantage of free or reduced-cost resources offered by your specialty association. Examples include:

Don’t forget to also check out the free resources offered by your Technical Assistance (TA) Contractor. TA Contractors offer specialty guides to tailor MIPS to your profession. To find your TA Contractor, click here.

Monthly Observance – National Preparedness Month

September marks National Preparedness Month in the United States, an annual observance to promote family and community disaster planning. As COVID-19 continues to spread across the globe, the importance of disaster planning is particularly relevant in 2020. Consider taking this month to help prepare your patients and your practice for future emergencies.

Emergencies and disasters are unpredictable and can take many forms, but there are some common steps that individuals, families, communities, and businesses can take to be better equipped to deal with disasters when they arise. The U.S. Department of Homeland Security website Ready.gov breaks National Preparedness Month into 4 themes, each with its own week. The themes are: 1) Make a Plan, 2) Build a Kit, 3) Prepare for Disasters, and 4) Teach Youth about Preparedness.

In addition to speaking to your patients about their preparedness, you should also have a plan in place for how your practice will deal with an emergency. Your plan should include items such as how you will alert patients if your practice needs to temporarily close, plans for care continuity, and record security and access in the case of a power outage or property damage.

Should your practice encounter a disaster or emergency that interferes with your ability to participate in MIPS, you may consider applying for an Extreme and Uncontrollable Circumstances Exception. More information about that process can be found on the QPP CMS website. Please note that practices experiencing hardship due to the COVID-19 pandemic can apply for this exception until December 31, 2020. Applications will be reviewed on a case by case basis. Read more about 2020 Performance Year Flexibilities here.

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