MIPS Reporting: Submitting Data through QPP.CMS.GOV
Sam Ross, QPP Advisor/Manager
January 31, 2018
Visit our website at http://qpp-il.org! We will help you navigate the complexities of the new CMS payment models so you can focus on what you do best – taking extraordinary care of your patients.
When you sign up for the QPP Resource Center, you get access to resources that help you establish your baseline, identify goals, learn about requirements, and monitor progress. Plus, QPP Advisors are available to answer questions as they come up. All assistance is offered free-of-charge thanks to a grant from CMS.
Agenda
• Brief MACRA/QPP Overview
• QPP.CMS.GOV Sign In and Navigation
• Entering Data for MIPS Categories• Quality• Advancing Care Information• Improvement Activities
• Additional Considerations and References
Brief MACRA/QPP Overview
MACRA (2015)
• Repeals “Sustainable Growth Rate”
• Streamlines multiple quality programs
• Expands pathways for level of risk and reward
• Supports multi-payer initiatives
2017 QPP Eligibility
1) Billing > $30,000 and treating 100+ Medicare patients per year (MIPS)
or
2) Treating 20% patients/receiving 25% of Medicare payments through an Advanced Alternative Payment Model (AAPM)
Merit-based Incentive Payment
System (MIPS)
Advanced Alternative
Payment Models (AAPM)
2017 QPP Timeline
Sign In and Navigation
QPP Sign In Page
• Enter EIDM User ID and Password
• Click the box for “Yes, I agree.” to the statement of truth
• Click the Sign In button
Verify One-Time Code
• A code will be sent to the Multi-Factor Authentication (MFA) device registered with EIDM account (phone, email, voice)
• Retrieve the code, enter into the text box, and click “Submit Code” button
Account Dashboard
• Practices for which your EIDM account can submit are displayed• Special status (small practice, non-patient facing, HPSA, rural, hospital-
based, ASC) identified for each practice
Manage User Access Page
• Click “Manage User Access”• Connected practices and permissions display with link to CMS Portal to
add/update/remove user access to TINs through EIDM account
Help and Support Page
• Click “Help and Support”• Click any button to navigate to that support section (videos, webinars, etc.)
Collapse/Expand
• Click “Collapse” to shrink the side navigation bar for more page real estate• Click “Expand” to return to normal size side navigation bar
CollapsedExpanded
Accessing the Reporting Module
• Click “Account Dashboard”• Click “As a group” or “As individuals” under the REPORT header
• Side navigation shows practice name and TIN when using group reporting• Side navigation also shows clinician name and NPI when using individual
Side Navigation – Group vs Individual
Group Reporting Dashboard
• Click category to report from navigation side bar OR • Click “Start Reporting” button under category name
• Individuals linked to the group TIN will appear under “Connected Clinicians”*• Enter reporting module for each MIPS category by clicking category name
under the REPORT header (next to clinician you are reporting for)
* If clinicians for whom you need to report are missing, they must be linked to the practice/TIN through PECOS at https://pecos.cms.hhs.gov/
Connected Clinicians (Individual Reporting)
Entering Data for MIPS Categories: Quality
Quality – No Existing Data
• Option 1: Upload QRDA or QPP file (self-submission)• Option 2: Contact registry/CEHRT for support with submission on your behalf• Click “File Upload” button to upload your own file
Upload Submission Data
• Click “browse” when the pop-up window appears
Upload Submission Data
• Find the file on your computer and click “Open”
Upload Submission Data
• File(s) will display with option to upload/remove one file at a time or all at once
Upload Submission Data - Errors
• File(s) will display with a status of “Upload Failed”• Click “Upload Failed” to review errors, which can be sent to CEHRT technical
support for analysis to fix issues with QRDA/QPP file formatting
Upload Submission Data - Success
• File(s) will display with a status of “Complete”• Click the “Close” button to exit the upload pop-up window and review
data that was included in the file
Quality – Existing Data
• “File Upload” button still exists to over-write previous upload• “Delete Category Data” button will remove data previously uploaded• Score(s) by submission method display below
Measures that Count
• Scroll down to see summary of submission• System automatically picks best 6 measures that count towards Quality• Each measure will display performance rate and score
Measure Details
• Click the > icon to the left of a measure name to show details
• Displays performance against benchmark and explanation of points earned from decile performance and bonus
Measures with Bonus Points
• Scroll down to see all measures that earned bonus points• Bonus for high-priority/patient experience measures, outcome measures
and/or measures submitted via end-to-end electronic reporting
Measures Submitted but Not Counted
• Scroll down to see all measures included in QRDA/QPP file that were not in the top 6 and do not count towards Quality score
• Can still click > icon to review details on benchmark and points that
would have been earned if the measure were in the top 6
Quality – Additional Submission Methods
• If additional data is uploaded (by you or on your behalf by CEHRT/registry vendor) via another submission method, an additional score will display
• Click “View Details” in the greyed out section to review measures• System will display both but automatically choose your highest score
Entering Data for MIPS Categories: Advancing Care Information
Advancing Care Information – No Existing Data
• Option to use “File Upload” with QRDA/QPP file (same as Quality)• Otherwise, start by selecting your performance period
Select Measure Set
• Each measure set is described• To identify what CEHRT supports, enter keyword in box (optional)• Click “Search” to query products listed on the CHPL
Select Measure Set
• Pop-up window appears with search results• Click the version of the product you used during reporting period
Select Measure Set
• After choosing product, pop-up window will close• Based on CEHRT Edition Year, select from available measure sets
Attestation Statements
• Before entering ACI measure results, you must review and respond to three attestation statements
• Click the > icon to expand and view entire statement• First two statements require agreement (click “Yes”)• Third statement is optional agreement
Enter Measure Data – Base Score
• First section will be measures required for base score• Must enter numerator/denominator or answer Yes/No for all• Pink “thumbs up” icon indicates measure is met
Enter Measure Data – Performance Score
• Next section is Optional Performance Measures• Enter numerator/denominator or answer Yes/No• Performance score points for each measure displays after answering• Category score updates in real time as you add data (pink bar at top)
Enter Measure Data – Bonus Score
• Next section is Additional Registry Bonus• Answer Yes/No to each registry reporting measure• Bonus score points display after answering each question
Enter Measure Data – Improvement Activities Bonus
• Last section is Improvement Activities Bonus• Answer Yes/No to the question• System alerts if you have not attested to any Improvement Activities that
qualify for a bonus, with link to Improvement Activities page• Bonus score points display after answering (“N/A” if no points earned)
Entering Data for MIPS Categories: Improvement Activities
Improvement Activities – No Existing Data
• Option to use “File Upload” with QRDA/QPP file (same as other categories)• Otherwise, start by selecting your performance period• Performance period must be at least 90 days to earn any points
Search for Activities
• Click “Filters” to filter by sub categories, weight or CEHRT bonus eligible• Enter search terms to filter by keyword
Advancing Care Information – CEHRT Version
• Click “Yes” to select activity (turns into green check mark)• Category points will update after selection, with “Category Success” noted
in upper right when reaching maximum score
Additional Considerations and References
Additional Considerations
• There is no “submit” or “save” button anywhere on the QPP submission site
• Data can be added/deleted/updated until window closes on 3/31
• CMS will automatically accept data resulting in the best score
• Same website will be used to show final scores, comparison against national results, and payment adjustments (scheduled for summer)
Additional Considerations
• Quality• Download/request QRDA file from your CEHRT vendor and test upload• Data submitted via claims or CMS Web Interface will not display(?)• Data submitted by ACO will not display(?)
• Advancing Care Information• Download/request QRDA file (upload) or ACI report (manual attestation)
from your CEHRT vendor• Only required category for ACO practices to self-submit (report as a group)
• Improvement Activities• Download/request QRDA file (upload) or IA report (manual attestation) from
your CEHRT vendor; or document which IA you met in advance• System is scoring incorrectly for small practices
• Should score medium-weight = 20, high-weight = 40• CMS has assured this will be fixed/scored correctly
Quality Payment Program of Illinois
http://qpp-il.org
844-QPP-DESK (844-777-3375)
THANK YOU!!