2019 mips data submission: advice for solo ... - …feb 03, 2020 · to determine whether a...
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2019 MIPS Data Submission: Advice for Solo or Small Group Practices
February QPP SURS LAN Webinar Questions and Answers
February 18 and 20, 2020
Resources:
For free MIPS Technical Assistance, contact: o FL, GA, NC, SC: Alliant GMCF
Phone: 844-777-8665 Email: [email protected] Submit request: https://www.surveymonkey.com/r/QPPHelpForm Website: http://www.alliantquality.org/
o AR, MO, OK, TX, PR, LA, MS, CO, KS: TMF Health Quality Institute Phone: 844-317-7609 Email: [email protected] Submit request: https://tmf.org/QPP/Request-Help Live chat: https://chat.tmf.org:8443/ECCChat/chat.html To join TMF’s Learning and Action Network: https://www.tmfqin.org/qpp
o AL, TN: QSource
Phone: 844-205-5540
Email: [email protected]
o NJ, PA, DE, WV: Quality Insights
Phone: 877-497-5065
Email: [email protected]
Website: https://www.qualityinsights.org
o NY, MD, DC, VA: IPRO
Phone: 866-333-4702
Email: [email protected] (change state code depending on the
state you practice in)
Submit request: https://ipro.org/for-providers/medicare-qpp/req-tech-assist
o WA, ID: Comagine Health
Phone: 877-560-2618
Email: [email protected]
Website: http://medicare.qualishealth.org/projects/QPP-resource-center
o MT, WY, UR, NV, OE, AK: Network for Regional Healthcare Improvement (NRHI)
For UT, OR, NV: Email: [email protected]
For MT, WY, AK: Email: [email protected]
o ND, SD, NE, IA: Telligen
Phone: 844-358-4021
Email: [email protected]
Submit request: https://telligenqpp.com/contact/
o MN, WI, MI, IL, IN, OH, KY: Altarum
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Email: [email protected]
o ME, NH, MA, VT, RI, CT: Healthcentric Advisors
Email: [email protected]
o NM, AZ, CA, HI: Health Services Advisory Group (HSAG)
Phone: 844-472-4227
Email: [email protected]
General QPP Information:
o QPP CMS Website: https://qpp.cms.gov/
o QPP CMS Resource Library: https://qpp.cms.gov/about/resource-library
o Locate your QPP SURS Technical Assistance Contractor:
https://qpp.cms.gov/about/small-underserved-rural-practices
o QPP Participation Status Tool: https://qpp.cms.gov/participation-lookup
o Technical Assistance Resource Guide: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/25/TA%20Resource%20Guide%202017%2004%20
24_Remediated.pdf
o Explore Measures Tool: https://qpp.cms.gov/mips/explore-measures/quality-measures
o QPP Access User Guide: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/335/QPP+Access+User+Guide.zip
o 2020 Quality Payment Program Final Rule:
https://www.federalregister.gov/documents/2019/11/15/2019-24086/medicare-
program-cy-2020-revisions-to-payment-policies-under-the-physician-fee-schedule-and-
other
o LAN Webinar Recordings, Transcripts, Q&As, and Slides: https://qppsurs.com/webinar-
resources/
2020 Performance Year:
o 2020 Part B Claims Reporting Quick Start Guide: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/820/2020%20Part%20B%20Claims%20Reporting%
20Quick%20Start%20Guide.pdf
o 2020 Cost Quick Start Guide: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/816/2020%20Cost%20Quick%20Start%20Guide.pd
f
o 2020 Qualified Registry Qualified Posting: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/803/2020_Qualified_Registry_Qualified_Posting_v
2.xlsx
o 2020 Qualified Clinical Data Registry Qualified Posting: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/802/2020_QCDR_Qualified_Posting_v2.0.xlsx
2019 Performance Year:
o 2019 Claims Data Submission Fact Sheet: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/444/2019%20Claims%20Data%20Submission%20F
act%20Sheet.pdf
o 2019 QPP Data Submission User Guide: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/901/2019%20QPP%20Data%20Submission%20Use
r%20Guide.pdf
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o Manual Attestation of Improvement Activities Measures:
https://www.youtube.com/watch?v=8vjPeLxe9dA&feature=youtu.be
o Manual Attestation of Promoting Interoperability Measures:
https://youtu.be/UUfmDiXUByc
o 2019 MIPS Promoting Interoperability User Guide: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/0/2019%20MIPS%20Promoting%20Interoperabilit
y%20User%20Guide.pdf
o 2019 MIPS Opt-In and Voluntary Reporting Policy Fact Sheet:
https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=2ahUKE
wj42YXz9eDnAhVDIKwKHV2nBrMQFjAAegQIChAB&url=https%3A%2F%2Fqpp-cm-prod-
content.s3.amazonaws.com%2Fuploads%2F488%2F2019%2520MIPS%2520Opt%2520In
%2520and%2520Voluntary%2520Reporting%2520Fact%2520Sheet.pdf&usg=AOvVaw3
USTkDp8FL8a2Vp0UaNiI2
o 2019 Opt-In and Voluntary Reporting Election Toolkit: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/743/2019%20Opt-
In%20and%20Voluntary%20Reporting%20Election%20Toolkit.zip
o 2019 Qualified Registry Qualified Posting: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/348/2019%20Qualified%20Registry%20Posting_Fi
nal_v9.xlsx
o 2019 Facility-based Measurement Fact Sheet: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/454/2019%20MIPS%20Facility-
Based%20Measurement%20Fact%20Sheet.pdf
o 2019 Promoting Interoperability Measure Specifications: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/343/2019%20Promoting%20Interoperability%20M
easure%20Specifications.zip
o 2019 MIPS Data Validation Criteria: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/436/2019%20MIPS%20Data%20Validation%20Crit
eria.zip
o 2019 Cost Performance Category Fact Sheet: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/351/2019%20Cost%20Performance%20Category%
20Fact%20Sheet.pdf
o 2019 MIPS Promoting Interoperability Fact Sheet: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/487/2019%20MIPS%20Promoting%20Interoperabi
lity%20Fact%20Sheet.pdf
o 2019 Data Submission FAQs: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/827/2019%20Data%20Submission%20FAQs.pdf
2018 Performance Year:
o 2018 QPP Performance Data Infographic: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/794/QPP%202018%20Performance%20Data%20In
fographic.pdf
o 2018 Performance FAQs: https://qpp-cm-prod-
content.s3.amazonaws.com/uploads/581/2018%20Performance%20Feedback%20FAQs.
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Questions and Answers February 18 & 20, 2020
Eligibility: 1. I have an extremely old system I use to submit my claims so I can't upload to a registry. This
means I spend hours every year entering patients and each encounter individually. Is there an easier way? I work for a solo practitioner who is strictly an acute inpatient rehabilitation facility. For free one-on-one assistance with reporting MIPS measure data using Medicare Part B claims,
contact your Technical Assistance Contractor. Many Technical Assistance Contractors have
published resources with helpful workflow tips and claims coding cheat sheets to assist small
practices with claims reporting and minimize the reporting burden. For further details on how to
submit quality data through claims in 2019, see the 2019 Claims Data Submission Fact Sheet. For
information on how to utilize Medicare Part B claims to report participation in the Quality
performance category, see the 2020 Part B Claims Reporting Quick Start Guide.
If you are interested in reporting through a Qualified Registry (QR) or Qualified Clinical Data
Registry (QCDR), some will work with practices to help them prepare and submit their MIPS data
through an Excel spreadsheet, and the registry will submit the data electronically to CMS. It may
be useful to contact a specific registry to get information on all the reporting options for your
practice. Additionally, your Technical Assistance Contractor may be able to help you understand
your registry reporting options.
2. I was not an eligible practitioner for 2019 but I opted into MIPS reporting. Will I always be required to opt in even if I am not eligible in the future years?
If you opt-in for the 2019 Performance Year, the election will only apply for the 2019
Performance Year. You will not be required to participate in future years if you opt-in only for the
2019 performance period, unless you become eligible by exceeding the low-volume threshold. If
you are eligible to opt-in in future years, you would have to opt-in again for each performance
year.
MIPS eligibility is determined each performance year independently of future performance years.
For Performance Year 2019, the MIPS eligibility determination period consists of the two 12-
month segments:
Segment #1: A 12-month segment beginning on October 1, 2017 and ending on
September 30, 2018, plus a 30-day claims run out; and
Segment #2: A 12-month segment beginning on October 1, 2018 and ending on
September 30, 2019. Segment #2 does not include a claims run out period.
3. Does a physician have to meet all three criteria to submit MIPS data?
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If a physician is a MIPS eligible clinician type and exceeds all three components of the low-volume threshold, he/she is required to report to the MIPS program. Under the low-volume threshold, clinicians are MIPS eligible if they:
1. Bill more than $90,000 in Medicare Part B allowed charges for covered professional
services payable under the Physician Fee Schedule (PFS); and
2. Provide covered professional services for more than 200 Part B-enrolled patients; and
3. Provide more than 200 covered professional services to Part B-enrolled patients.
To determine whether a physician meets the low-volume threshold, CMS reviews past and current Medicare Part B Claims and Provider Enrollment, Chain, and Ownership System (PECOS) data for clinicians and practices twice for each Performance Year. Clinicians and practices must exceed the low-volume threshold (LVT) during two review periods to be eligible for MIPS. If the provider meets one or two, but not three of the above components, then he/she is eligible to opt-in to the MIPS program. If you choose to opt-in and report data, you will be subject to MIPS scoring and subsequent payment adjustments. Please note that once an election to opt-in is made, it is final and cannot be reversed. The best way to determine your eligibility for MIPS is to enter your NPI in the QPP Lookup Tool on the QPP website. For more information on how to opt-in to MIPS, see the 2019 Opt-In and Voluntary Reporting Election Toolkit.
4. In a 2 MD practice, if one physician is required to report to MIPS, but the other is not, is it best to report as an individual or as a group? The decision to report your MIPS data as a group or an individual should be based on your specific situation. To find out if you are eligible to report to the MIPS program as an individual or as a group, please enter your NPI in the QPP Lookup Tool. Your local Technical Assistance Contractor can assist you with making the decision to report as an individual or as a group. To locate your region’s Technical Assistance Contractor, click here.
Data Submission: 5. We are a specialist office and our doctors are independent but perform surgeries at the
hospital. Some of our quality measures are only captured by the hospital and the hospital’s registry worked closely with them. We are not sure if any other registry could get that data or not. Please reach out to your registry to confirm which data they were able to collect and submit on your practice’s behalf. You can also login to the QPP Portal to review MIPS data that was submitted by a third-party vendor on your behalf. For assistance reporting to the MIPS program, please reach out to your local Technical Assistance Contractor.
6. Can we submit quality by QRDA III file uploaded to QPP Portal and also report Improvement Activities by attesting directly on the QPP Portal? Yes, you can submit data for the Quality performance category by uploading a QRDA III file to the QPP Portal. You can also submit an attestation for the Improvement Activities performance category via the QPP Portal. For more information on data submission, please see the 2019 QPP Data Submission User Guide. For more information on how to attest to the Improvement
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Activities performance category, please watch the Manual Attestation of Improvement Activities Measures video.
7. I've been accessing the QPP Portal for the past 2 years but don't recall registering for HARP. Does the fact that I can log in and see all my clinicians and group data indicate that I've completed the HARP registration in the past? Yes, being able to log in to the QPP Portal indicates that you have a HARP account. If you do not recall registering for a HARP account, you likely had an EIDM account that was transferred to a HARP account. For more information on how to log in to your HARP account, see the QPP Access User Guide.
8. What is the date for attestation? The deadline to submit data for the 2019 Performance year is March 31, 2020 at 8:00 pm ET. Please note that the 2019 performance period ended on December 31, 2019; therefore, Improvement Activities and Promoting Interoperability measures must have been completed by December 31, 2019. For more information on how to attest to the Promoting Interoperability and Improvement Activity categories, please watch the Manual Attestation of Promoting Interoperability Measures and Manual Attestation of Improvement Activities Measures videos.
Claims-Based Reporting: 9. Do you foresee claims measures going away?
Claims measures are only available for small practices (15 or fewer clinicians) but will be available for small practices (15 or fewer clinicians) for the foreseeable future. CMS is aware that small practices may have limited resources which may make it difficult for them to participate in MIPS via other submission types.
Certified Electronic Health Record Technology (CEHRT): 10. Will the QPP Portal show what our vendor has submitted? Or do we need to look at our
vendor information to see what has been submitted? Whether you are uploading data directly to the QPP Portal, or a third-party vendor is submitting data on your behalf, you should log into the QPP Portal to review your submitted MIPS data. For instructions on how to access the QPP Portal, please see the QPP Access User Guide.
11. Our data file is in our EHR’s format and cannot be uploaded into the QPP Portal without using (at an additional cost) a third party to convert the format. Why can’t my EHR provide the correct format or CMS accept the EHR format? Do you need your EHR CEHRT ID if a third-party vendor is submitting for you?
Your EHR vendor should be able to provide you with a QRDA III file that you can upload to the
QPP Portal. EHR vendors must be able to either (1) transmit data from the certified EHR or
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through a data intermediary in the CMS-specified form and manner, or (2) enable the individual
MIPS eligible clinician and group to submit data directly from their certified EHR in the CMS-
specified form and manner. You must provide your EHR’s CEHRT ID number so that CMS can
verify you are using 2015 Edition CEHRT. If you don’t provide this ID, you will receive a score of 0
for the Promoting Interoperability performance category. Please use the Certified Health IT
Product List (CHPL) on the Office of the National Coordinator for Health Information Technology
(ONC) website to generate a CEHRT ID number.
CMS and the ONC established standards and criteria for structured data that certified EHRs must
meet in order to meet the reporting requirements of the Promoting Interoperability category.
The ONC certifies vendor products each year under the CEHRT requirements and criteria.
Sometimes a vendor fails to meet the requirements in a given year and is required to take
corrective action or may be decertified. To find out which EHR systems meet the CEHRT
requirements, please see the CHPL. If you believe your CEHRT is functioning incorrectly, you may
file an official complaint. Additional information on the Certified Health IT Complaint process is
available here.
12. Can you still get the bonus points for using a CEHRT if you attest via the QPP Portal? Or do you
have to go through your EHR vendor or a qualified registry? MIPS eligible clinicians can earn 1 bonus point for each measure that meets end-to-end reporting criteria and uses CEHRT. For eCQMs, you can earn the end-to-end electronic reporting bonus via Login and Upload submission type using a QRDA III file or via Direct Login and Upload using a QPP JSON file. For MIPS CQMs where there is no eCQM equivalent, you can earn the end-to-end reporting bonus via Direct Login and Upload using a QPP JSON file. When reporting a measure with an eCQM equivalent, you must submit the eCQM extracted from your 2015 edition CEHRT to earn the end-to-end bonus points. Please note that reporting a “yes” to the completion of at least 1 of the specified Improvement Activities using CEHRT will no longer result in a 10% bonus in the 2019 Performance Year.
Promoting Interoperability: 13. I just received a call from our EHR saying we cannot attest for the Promoting Interoperability
category due to the EHR not being able to connect with the bidirectional interface for the immunization registry. I just received this information on February 13th so did not submit an exclusion request. He told me that we would not get a negative payment adjustment, but we would lose 25 pts. Can the EHR apply for these exclusions for the practice? It is not too late to claim an exclusion for the Immunization Registry Reporting measure. The deadline to submit data for the 2019 Performance year is March 31, 2020 at 8:00 pm ET. To meet the requirements for the Public Health and Clinical Data Exchange objective, you must be actively engaged with two different public health agencies or clinical data registries. You may choose from the following five measures: Immunization Registry Reporting, Electronic Case Reporting, Public Health Registry Reporting, Clinical Data Registry Reporting, and Syndromic Surveillance Reporting. Each of the five measure has their own exclusions. If you claim an exclusion for one measure, but submit a “yes” response for another measure, you can still earn
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the full 10 points for the objective. Any MIPS eligible clinician meeting one or more of the following criteria may be excluded from the Immunization Registry Reporting measure if the MIPS eligible clinician:
1. Does not administer any immunizations to any of the populations for which data is collected by its jurisdiction’s immunization registry or immunization information system during the period of performance; OR
2. Operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required to meet the CEHRT definition at the start of the performance period; OR
3. Operates in a jurisdiction where no immunization registry or immunization information system has declared readiness to receive immunization data as of 6 months prior to the start of the performance period.
The Public Health and Clinical Data Exchange measures will be awarded full points if a “yes” is submitted for 2 registries or one “yes” and one exclusion. If there are no “yes” responses and two exclusions are claimed, the 10 points will be redistributed to the Provide Patients Electronic Access to Their Health Information measure. Please contact your local Technical Assistance Contractor for assistance reporting to the MIPS program.
14. Did you have to obtain an official approval for a Promoting Interoperability exclusion if you have fewer than 100 transitions? For Public Health and Clinical Data Exchange can I just claim an exclusion? If you qualify for exclusions, you can claim them through the Log-in and Attest, Log-in and Upload, or Direct submission types. When submitting via the Log-in and Attest submission type, check the box below the appropriate measure(s) to indicate the exclusion. When submitting data via the Log-in and Upload or Direct submission types, submit the appropriate exclusion measure. You do not need to obtain written approval for a Promoting Interoperability measure exclusion. If you qualify for and claim the exclusion for one or more of the required Promoting Interoperability performance category measures, then the points for the required measure would be redistributed to another measure or measures. You can claim an exclusion for the Support Electronic Referral Loops by Sending Health Information measure if you are a MIPS eligible clinician who transfers a patient to another setting or refers a patient fewer than 100 times during the performance period. You can claim an exclusion for the Support Electronic Referral Loops by Receiving and Incorporating Health Information if you are a MIPS eligible clinician who receives fewer than 100 transitions of care or referrals or has fewer than 100 encounters with patients never before encountered during the performance period. The Support Electronic Referral Loops by Sending Health Information and Support Electronic Referral Loops by Receiving and Incorporating Health Information measures are included in the Health Information Exchange objective. The Public Health and Clinical Data Exchange objective includes the Immunization Registry Reporting, Electronic Case Reporting, Public Health Registry Reporting, Clinical Data Registry Reporting, and Syndromic Surveillance Reporting measures. Each of these five measures has their own exclusions. Please refer to the 2019 Promoting Interoperability Measure Specifications to review the exact exclusion criteria for each measure. Generally speaking, the exclusions are based on the following criteria:
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1. Does not diagnose or directly treat any disease or condition associated with an agency/registry in their jurisdiction during the performance period.
2. Operates in a jurisdiction for which no agency/registry is capable of accepting electronic registry transactions in the specific standards required to meet the CEHR definition at the start of the performance period.
3. Operates in a jurisdiction where no agency/registry for which the MIPS eligible clinician has declared readiness to receive electronic registry transactions as of six months prior to the start of the performance period.
For more information on the Promoting Interoperability performance category, please see the 2019 MIPS Promoting interoperability Performance Category Fact Sheet.
15. What supporting documentation is necessary for the small practice hardship exception for
Promoting Interoperability since the only requirement is being designated a small practice by CMS? MIPS eligible clinicians, groups, and virtual groups may submit a Promoting Interoperability (PI) Hardship Exception Application citing one of the following specified reasons:
MIPS eligible clinician in a small practice
MIPS eligible clinician using decertified EHR technology
Insufficient internet connectivity
Extreme and uncontrollable circumstances
Lack of control over the availability of CEHRT
Small practices that apply for a PI Hardship Exception are not required to submit any supporting documentation. That being said, we recommend you retain documentation of your circumstances in case CMS requests data validation or in the event of an audit. For more information on suggested documentation to maintain in case of audit, see the 2019 MIPS Data Validation Criteria. Please note that the PI Hardship Exception Application for Performance Year 2019 closed on December 31, 2019. If you receive a Hardship Exception for the PI category, the PI category would receive a weight of 0 in calculating your final score, and the 25 points will be reallocated to the Quality category, making the Quality category worth 70 points. More information on MIPS Exceptions can be found at https://qpp.cms.gov/mips/exception-applications.
Cost Category: 16. On my performance score for 2018, Cost category was N/A. I thought this score was
automatically generated by CMS. Why would I not get a score? The cost category is only scored for clinicians and groups who met the minimum number of cases to calculate at least one cost measure (either the Total Per Capita Cost measure or the Medicare Spending Per Beneficiary measure). MIPS eligible clinicians will see cost measure information in performance feedback. If you don’t see any cost measure details and see a score of “N/A” in the “Final score at a glance,” then you or your group did not meet the case minimum for either cost measure and the weight for this performance category was reallocated to another performance category (typically Quality). The minimum case volume for the Medicare Spending Per Beneficiary (MSPB) measure is 35, meaning 35 MSPB episodes must be attributed to a MIPS eligible clinician or group for the measure to be scored. The case minimum for the Total Per
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Capita Cost (TPCC) measure is 20. For a MIPS eligible clinician participating in MIPS as an individual, the minimum number of cases must be assigned to the individual MIPS eligible clinician’s TIN-NPI for either measure to be scored. For groups of clinicians participating in MIPS as a group, the minimum number of cases must be assigned to TIN-NPIs across the TIN-NPIs under the group’s TIN for either measure to be calculated for the group. For more information on the Cost Category, see the 2019 Cost Performance Category Fact sheet and the 2018 Performance Feedback FAQs.
17. Like last year, we don't have to submit anything for the Cost category, right? The data is just taken from our claims. As was the case in previous years, in Performance Year 2020, CMS will use Medicare claims data to calculate Cost measure performance, so eligible clinicians do not have to submit any additional data for this performance category. There are a few new changes to the Cost category in 2020:
CMS updated the name of the Medicare Spending Per Beneficiary measure. It is now called the Medicare Spending Per Beneficiary Clinician (MSPB-C) measure. For this measure, CMS refined the attribution methodology for medical and surgical episodes and included service exclusions for costs that are unlikely to be influenced by clinicians.
CMS also revised the Total Per Capita Cost (TPCC) measure. CMS refined the attribution methodology for identifying the primary care relationship, included specialty exclusions for clinicians who don’t provide primary care services, and refined risk adjustment to account for changes in patient health status during the year.
CMS also added 10 new Episode-based cost measures.
For more information on the Cost category, please see the 2020 Cost Performance Category Quick Start Guide.
Payment Adjustments: 18. What is the highest adjustment an individual or group received for 2018?
The maximum payment adjustment for eligible clinicians who achieved a positive and exceptional performance adjustment was 1.68% for Performance Year 2018. For more information on the 2018 performance data, please see the 2018 QPP Performance Data Infographic.