IN THIS ISSUE

Calculating MIPS Scores and

Payment Adjustments

Preparing for MIPS in the

Small Group Practice: Q&A

Spotlight on Advancing

Care Information

MIPS Improvement

Activities

National Recovery Month

SURS Spotlights

This newsletter is produced by

IMPAQ International who is

functioning as the QPP SURS

Central Support contractor.

Questions or suggestions about

the newsletter can be sent to

QPPSURS@IMPAQINT.COM.

SEPTEMBER 2017

Calculating MIPS Scores and Payment Adjustments

Clinicians participating in the Merit-based Incentive Payment System (MIPS) path of the Quality

Payment Program should submit data from the 2017 performance period by March 31, 2018.

As depicted in the visual below for the “Test” option, submitting data on even one quality

measure or improvement activity will ensure that eligible clinicians do not receive a negative

4% adjustment to their Medicare payments.

The Details – There are four performance categories that can influence a clinician’s MIPS score and ultimately their

payment adjustment. Note that clinicians can avoid the negative payment adjustment by submitting only one measure for

either the quality category or improvement activities category.

1. Quality (60% of MIPS final score): Clinicians that choose the Test option can submit only one measure in this category

(with no measures in any of the other categories), while clinicians that choose to submit Partial Year and Full Year

data need to submit six measures.

2. Advancing Care Information (25% of MIPS final score): Clinicians that choose the Test option can submit four or five

base score measures in this category depending on their edition of CEHRT (with no measures in any of the other

categories), while clinicians that choose to submit Partial Year and Full Year data need to submit performance score

or bonus score measures in addition to the base score.

3. Improvement Activities (15% of MIPS final score): Clinicians that choose the Test option can attest to only one

improvement activity (with no measures in any of the other categories), while clinicians that choose to submit

Partial Year and Full Year data need to attest to either two high-weighted activities, one high and two medium-

weighted activities, or four medium-weighted activities. Possessing a special consideration for being a small

practice doubles the points behind the activity.

4. Cost: Not required for 2017.

Continued on Page 2

2 QPP SURS NEWSLETTER | SEPTEMBER 2017

In June 2017, the Centers for Medicare & Medicaid Services (CMS) and IMPAQ International hosted two webinars to help small practices – with a special focus on those in rural and underserved areas – start the process of preparing to actively participate in the Merit-based Incentive Payment System (MIPS). Below we highlight a few frequently asked questions:

Q: If several physicians are filed under the same tax ID, do they report as a group or separately? A: You can participate in MIPS as either an individual or as part of a practice in which everyone bills under a single Tax Identification Number (TIN). Just because you are a part of a practice that has multiple clinicians included in MIPS, it does not mean that you have to participate as a group; it is an option available to you. However, you must participate as an individual or as a group for all of the MIPS performance categories; you cannot submit as an individual for one MIPS performance category and at the group level for others. The options to participate as an individual or as a group are discussed in the following slide deck beginning on slide 16. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/QPP-Participation-Criteria-Webinar-Slides.pdf Q: What platforms are available to report measures to MIPS? A: For individuals, you can submit data for the Quality performance category through a Qualified Clinical Data Registry (QCDR), Qualified Registry, Electronic Health Record, or Claims. Groups have similar options in the QCDR, Qualified Registry, and Electronic Health Record. Groups may also report via Administrative Claims1, CMS Web Interface (for groups of 25 or more), and Administer the CAHPS for MIPS Survey (this must be

reported with another submission method), but registration for the CMS Web Interface and CAHPS for MIPS Survey is now closed for the 2017 performance period. More information is available at: https://qpp.cms.gov/learn/getprepared. Q: What are the relevant deadlines? A: The first performance period began January 1, 2017 and ends December 31, 2017. If you did not start collecting performance data on January 1, you can choose to begin anytime between January 1 and October 2 (October 2, 2017 is the last day to begin par-tial year reporting). Data submission for 2017 is due no later than March 31 2018. The submission window will open on January 1, 2018, and CMS encourages you to submit your data as early as possible to ensure that it has been received. If you are using third-party vendors for data submission they may have earlier deadlines. The first payment adjustments will go into effect January 1, 2019. More information on deadlines is included in: https://qpp.cms.gov/docs/Quality_Payment_Program_Overview_Fact_Sheet.pdf and https://qpp.cms.gov/docs/QPP_Quick_Start_Guide_to_MIPS.pdf.

1There is only one Quality measure that is an administrative claims measure -

the All-Cause Hospital Readmission Measure. This is applicable to groups of 16 or more clinicians with 200 attributed patients. If the group does not have 200 attributed patients, then they will not be scored on the measure. Therefore, it is not necessarily a data submission option.

Calculating MIPS Scores and Payment Adjustments (cont’d. from pg. 1)

Payment Adjustment – Small practices should reach out to their regional Direct Support Organization for specific

guidance on estimating their payment adjustment. To find the organization name and contact information for each

region, visit this website: https://qpp.cms.gov/about/small-underserved-rural-practices. There are also several tools

available to help estimate payment adjustments. See one such estimator here: https://www.stratishealth.org/providers/

data/MIPS-Estimator/.

Preparing for MIPS in the Small Group Practice: Questions and Answers

10 days until October 2,

2017 -- the last day to begin

partial year reporting!

3 QPP SURS NEWSLETTER | SEPTEMBER 2017

Spotlight on Advancing Care Information

In August 2017, the QPP SURS Central Support Contractor mapped the

2017 Advancing Care Information (ACI) transition measures to 2016 data

from the Electronic Health Record (EHR) Incentive Program to predict

performance in the MIPS ACI performance category. EHR Incentive

Program data were available for 40,340 SURS clinicians.

Clinicians reporting for MIPS must report all required measures in the ACI

performance category base score to meet test reporting requirements.

Required measures for the ACI base score include:

• Security Risk Analysis

• e-Prescribing

• Provide Patient Access

• Health Information Exchange

The visual below illustrates the number of ACI base score measures

reported by SURS clinicians in 2016. Of the 75% of SURS clinicians not

predicted to meet ACI reporting requirements, the majority were not

required to report certain measures as a result of meeting specific

exclusion criteria in the EHR Incentive Program. These clinicians will be

required to report all four base score measures under the MIPS system.

Continued on Page 4

WEBSITES

Centers for

Medicare and

Medicaid Services https://www.cms.gov

Quality Payment

Program

qpp.cms.gov

Healthcare

Communities healthcarecommunities.org

For FREE assistance

sponsored by CMS,

clinicians in small

practices can

contact their Direct

Support

Organization

https://

qpp.cms.gov/about/

small-underserved-

rural-practices

CONTACT US

QPP SURS Central

Support Team

(202) 774-1060

qppsurs@impaqint.com

CMS QPP Service

Desk

1 (866) 288-8292

1 (877) 715-6222 (TTY)

qpp@cms.hhs.gov

25%

of SURS clinicians are projected to

meet ACI test reporting

requirements

4 QPP SURS NEWSLETTER | SEPTEMBER 2017

Spotlight on Advancing Care Information (cont’d.

from pg. 3)

As illustrated in the visual to the

right, the majority of SURS clinicians

were able to report 2016 EHR

Incentive Program data on the first

three ACI base measures – Security

Risk Analysis, e-Prescribing, and

Provide Patient Access – but only 26

percent of the SURS clinicians

reported Health Information

Exchange data.

The graph below displays the average predicted percentage score among SURS clinicians who participated in the 2016 EHR Incentive Program for each of the performance score measures.

Continued on Page 5

5 QPP SURS NEWSLETTER | SEPTEMBER 2017

Spotlight on Advancing Care Information (cont’d.

from pg. 4)

The graph below displays the predicted ACI scores (sum of base score, performance score, and bonus

score) among SURS clinicians. Based on the EHR Incentive Program data, approximately one-quarter

of SURS clinicians are projected to achieve at least 20.25 points in the ACI performance category while

three-quarters are projected to achieve less than 15 points.

M

NT ACTIVITIE Note 1: Predicted ACI score does not include View, Download or Transmit (VDT) Measure (10%) and Reporting Improvement Activities

using CEHRT (10%).

Note 2: Percentage of SURS clinicians do not sum to 100% due to rounding.

14% of clinicians are projected to receive the full 25 points for the

Advancing Care Information Performance Category

SURS Spotlights: Resources from Altarum and HealthInsight The QPP SURS Direct Support Organizations have been developing and leveraging useful resources to help small

practices transition to the Quality Payment Program. This month’s newsletter features resources from Altarum and

HealthInsight:

1. Altarum’s Quality Payment Program Resource Center™ for the Midwest recently developed six educational

videos that include an overview of the Quality Payment Program, as well as a closer look at the four MIPS

Performance Categories and Alternative Payment Models. These videos can be found at https://

www.youtube.com/channel/UCPipfu41XGGV3Layj-QDUIQ.

2. HealthInsight has developed a nine-step guide to reporting in the Merit-based Incentive Payment System (MIPS), which the Network for Regional Healthcare Improvement has used to educate and transition its eligible clinicians into MIPS. This resource can be found at http://healthinsight.org/files/Quality%20Payment%20Program/Understanding%20the%20Quality%20Payment%20Program/MIPS%209%20steps%206-9-17.pdf.

6 QPP SURS NEWSLETTER | SEPTEMBER 2017

National Recovery Month

In September of every year, the United States Substance Abuse and Mental

Health Services Administration (SAMHSA) celebrates Recovery Month to raise

awareness about mental health and substance use disorders, and to show that

prevention works, treatment is effective, and people recover. This year’s Recov-

ery Month campaign is titled: “Join the Voices for Recovery: Strengthen Families and Communities.” Providers can use

Recovery Month logos, banner, flyers, posters and activity guides to spread this message of hope and to engage their

staff, patients, families, and communities.

Make Recovery Month Count

The Merit-based Incentive Payment System (MIPS) rewards providers for a wide range of activities that support the goals

of Recovery Month. For example, the following activities can all be conducted as part of an annual visit:

Spread the word and share these Recovery Month resources:

Visit SAMHSA’s Recovery Month website Access the Recovery Month toolkit

Access Recovery Month logos, banners, posters and flyers

What Clinicians Can Do Corresponding MIPS Measures

Use the PHQ-9 Tool to screen patients for major depressive disorder (MDD)

Quality Measure 371: Depression Utilization of the PHQ-9 Tool

Description: Patients age 18 and older with the diagnosis of major depression or dysthymia who have a Patient Health Questionnaire (PHQ-9) tool administered at least once during a 4-month period in which there was a qualifying visit

Assess suicide risk for patients who screen positive for MDD Quality Measure 107: Adult Major Depressive Disorder (MDD):

Suicide Risk Assessment

Description: Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified

Communicate with providers treating their patients with MDD for co-occurring conditions

Quality Measure 325: Adult Major Depressive Disorder (MDD):

Coordination of Care of Patients with Specific Comorbid Conditions

Description: Percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition

MIPS Improvement Activities: Connection to Quality Measures and Documentation for Audits

As small practices are actively participating or preparing to participate in MIPS for the 2017

transition year, they may be interested in exploring two key concepts in the improvement

activities category:

1. Selecting improvement activities that are connected to their quality measures, as this helps to

ensure practices stay focused on improving their top priority processes and outcomes; and

2. Maintain the level of documentation outlined in the data and validation package to support

attestation for their selected improvement activities in the event of an audit.