MIPS Tips (October)

October 28, 2019

The Merit-based Incentive Payment System (MIPS) 2019 reporting year is now in its last 90-days, and Quatris Healthco wants to ensure you are staying on track.

Category Corner – In this edition, we will focus on the Quality performance category of MIPS. Did you know that you can report more than six Quality measures? Below is additional information on how you could potentially earn more points towards your Quality performance category score:

  • Ways to earn bonus points:
    • Submit additional outcome or high-priority measures beyond the one required.
      • Two (2) bonus points for each additional outcome measure that meet case minimum and data completeness requirements and have a performance rate > 0% or < 100% for inverse measures.
      • One (1) bonus point each for additional high-priority measures that meet case minimum and data completeness requirements and have a performance rate > 0% or < 100% for inverse measures.
    • These bonus points are capped at 10% of the Quality performance category denominator (or the total number of available measure achievement points). This cap is separate from the cap on bonus points earned for end-to-end electronic reporting.
    • Please see the Toolbox Tactics section below on how to use CQR to determine which measures to report.
  • Data Completeness Standard defined:
    • Met or exceeded the minimum case volume of twenty (20) eligible cases (has enough data for it to be reliably measured);
    • Met or exceeded the 60% data completeness criteria; and
    • Had performance greater than 0% (or less than 100% for inverse measures).  
  • The above information is from the “2019 MIPS Scoring Guide” (found in the QPP Resource Library). 

Program Perks – In this section, we will focus on new and important updates from CMS on the Quality Payment Program. 

  • Did you miss the October 3, 2019 deadline for having all 2015 CEHRT requirements in place to report for the PI category of MIPS? You may be eligible for the PI Hardship Application.
    • The QPP Promoting Interoperability Hardship Application deadline is December 31, 2019.
    • For information on who is eligible to request a PI Hardship Application and the application process visit: QPP Exception Application.
    • This application does not prevent or exclude you from reporting the Quality and Improvement Activities using athenaPractice and CQR, however, if you are reporting the Quality category using CQR, you will still need to be upgraded to a version of 12.3 no later than December 31, 2019, to be compliant.
  • First vs. Second Eligibility Run
    • It is important to understand which provider(s) in your practice are REQUIRED to report to MIPS.  This is done through the QPP Participation Status tool. There are two (2) eligibility runs that CMS performs for the reporting year. Below is the explanation of the timing of the eligibility runs. Currently, only the FIRST eligibility run results are available on the QPP website.
      • Currently displays MIPS eligibility information for the performance year 2019 from the first review period (PECOS data and claims data from October 1, 2017-September 30, 2018). CMS will complete the second review and update the tool with the final 2019 eligibility information in November 2019. This will incorporate Medicare Part B claims data from October 1, 2018-September 30, 2019, and PECOS data. Your MIPS eligibility status may change from what is displayed in the tool upon completion of the first review period to completion of the second review period.
      • If you were determined to be ineligible after the first review period, that determination will not change. However, it is possible for a clinician and/or practice to be deemed “eligible” after the first review period and then deemed “ineligible” after completion of the second review period. It is very important to use the tool to review your MIPS eligibility information more than once: both after the first and second review periods are complete.

Measurement Metrics – In this section, we will focus on specific measures and how to improve your scores. 

  • Support Electronic Referral Loops by Receiving and Incorporating Health Information
    • This is a new measure for 2019. To further clarify this measure, let’s take a closer look at how the denominator and numerator are calculated.
      • Denominator count – For a patient to be counted in the denominator of the measure there are two (2) criteria:
        • The patient must have an imported CCDA on their chart
        • The patient must either be a new patient or, if they are established, have an office visit marked as “Encounter is Transition of Care.”
      • Numerator count – Of the patients in the denominator, the imported CCDA must be reconciled for the following three (3) criteria, even if no changes are made:
        • Medication – Review of the patient’s medication, including the name, dosage, frequency, and route of each medication
        • Medication allergy – Review of the patient’s known medication allergies
        • Current Problem List – Review of the patient’s current and active diagnoses.
  • CMS68 – Documentation of Current Medications
    • IMPORTANT REMINDER: While checking the box for Medications Reviewed provides credit in CQR, don’t lose sight of what will be requested in the event of an audit. If you are audited for this measure, they will be looking for the following criteria, as stated by the CMS specification for this measure, “This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.”
  • CMS138 – Preventive Care and Screening for Tobacco Use and Cessation Intervention
    • If you have achieved scores of 90% or higher but are still only seeing 3 points being given for this measure this may be an explanation as to why this is happening.
      • CMS is only looking at the second numerator/denominator results for this measure. Because of this change, there is not a benchmark available from CMS for this measure, therefore the maximum points to be achieved for this measure in 2019 are three (3). However, if there is enough data submitted during 2019, CMS will review this data and could benchmark the measure at the time the final scores are released. Eligible clinicians and groups are still encouraged to report this measure so that it can be benchmarked moving forward. 

Toolbox Tactics – In this section, we will focus on tips for how to use CQR the Quality Reporting tool to manage and monitor your progress. 

  • Using CQR to select your Quality measures
    • If you read the Category Corner section of this MIPS Tips, you know that you can receive additional points towards your Quality score by selecting more than six (6) measures on your CQR dashboard for attestation. Below is what to look for when selecting Quality measures for attestation:
      • Select your six (6) best performing measures, making sure to select at least one that is an Outcome measure or High Priority measure.
      • Look for any measures that are labeled as Outcome measures or High Priority measures that are not a part of your top six (6).
        • Outcome measures will be labeled in CQR under the “Type” Column as “Outcome” or “ITM Outcome”.
        • High Priority measures will be identified as those having an orange triangle with an exclamation mark next to the measure number under the “CMS#” column.
          • NOTE: You will not be able to “Select” more than six (6) measures with a checkmark in the “Sel” column, however any Quality measure appearing on the Dashboard at the time the QRDA-III is created will be included in the report. 
      • For those that are identified as additional Outcome and/or High Priority measures, make sure they meet the following criteria for earning additional bonus points:
        • Must have at least twenty (20) patients in the denominator. To view the number of patients in the denominator, click the green button next to the measure.
        • Must have a performance greater than 0 % (or less than 100% for inverse measures).
  • To create a worklist and print the list of unmet patients in CQR follow these steps:
    • PI Tab – Click on the blue number in the unmet column > click on the Last Name column header to put patients in alphabetic order (optional) > click PDF > select the desired location to save the PDF document to > Save > go to where the file was saved > open the PDF > Print the PDF.
    • Quality Tab – Click the green button next to the measure > click on the blue number in the unmet column > click on the Last Name column header to put patients in alphabetic order (optional) > click PDF > select the desired location to save the PDF document to > Save > go to where the file was saved > open the PDF > Print the PDF.

NOTE: If the option for PDF does not appear and you are only seeing what appears to be 3 “puzzle-looking” pieces > click one of the “puzzle-looking” pieces > you will receive a pop-up to Allow or Block > Click Allow > this may kick you out, but just go back through the above-listed steps and you will be able to save the list to a PDF document.

MIPS Consulting – Quatris Healthco offers quality consulting services to all of customers and will once again offer services for the 2020 reporting year. For information, contact mkeller@qhco.com. Note: The content of this email may not apply to your practice. Contact your EMR vendor on processes for support and quality reporting program.

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