MIPS 2021: MVPs and QCDR Changes Coming

MIPS Final Rule 2020

Last week, CMS released the final rule for the changes to the Merit-Based Incentive Payment System (MIPS). While there are only minor changes to the program in 2020, bigger changes are expected in 2021. Here are two of the big takeaways from the final rule.

MIPS Value Pathways (MVPs)

CMS intends to move toward what they say would be a more streamlined MIPS program. To fulfill upon this vision, the agency intends to reduce reported complexities with data submission and confusion surrounding measure selection with a new framework they are calling MIPS Value Pathways (MVPs).

In the MVP framework, CMS intends to work with stakeholders to create sets of measure options that they say would be more relevant to clinician scope of practice and meaningful to patient care. MIPS-eligible clinicians would no longer choose their measures from a single inventory, but would instead fulfill pre-defined measures and activities connected to a specialty or condition.

At this time, CMS has not determined whether participation in MVPs in 2021 would be optional or mandatory.

Many aspects of the MVP framework are still unclear, and we will be following and providing updates as they are released by CMS. Subscribe to our MIPS newsletter to keep up to date on the MVP discussion.

Qualified Clinical Data Registries (QCDR)

In the current QPP landscape, QCDRs are not required to support multiple MIPS performance categories. However, beginning in performance year 2021, QCDRs will be required to submit data for the Quality, Improvement Activities, and Promoting Interoperability categories for the entire performance year and applicable submission period.

CMS is looking to achieve alignment of similar measures across QCDRs, with an emphasis on outcome measures. Starting in 2021, this would require full measure development and testing at the clinician level prior to the time of self-nomination. Additionally, CMS would implement a set of formalized guidelines for QCDR measure rejections.

You can read more about these proposed changes in the Quality Payment Program final rule.

November 6th, 2019 Categories: featured, MIPS Information

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MIPS 2020: Key Takeaways

MIPS 2020 Final Rule

Last week, CMS released the final rule for the changes to the Merit-Based Incentive Payment System (MIPS) in 2020. Changes to the program next year are minimal, but are still important to note as you head into performance year 4.

Performance Category Weights

There will be no change to the performance category weights in MIPS performance year 2020.

MIPS Performance Categories

Payment Adjustment

For the 2020 performance period, the performance threshold (maximum number of points needed to avoid a negative payment adjustment) will increase from 30 to 45 points. The additional performance threshold for exceptional performance will increase from 75 points to 85.

The maximum positive payment adjustment for performance year 2020 will be increased to 9%, plus additional adjustments for exceptional performance. The maximum negative payment adjustment will be -9%.

Quality Performance Category

Data completeness for performance year 2020 will increase from 60% to 70%. This means you must report on at least 70% of your total patients who meet the measure’s denominator criteria in order to receive maximum points for the measure.

Improvement Activities Category

The Improvement Activities inventory has been updated for MIPS performance year 2020.

MIPS Year 4 Changes to Improvement Activities
Added
  • IA_BE_25: Drug Cost Transparency
  • IA_CC_18: Tracking of clinician’s relationship to and responsibility for a patient by reporting MACRA patient relationship codes
Modified
  • IA_PSPA_28: Completion of an Accredited Safety or Quality Improvement Program
  • IA_PM_2: Anticoagulant Management Improvements
  • IA_EPA_4: Additional improvements in access as a result of QIN/QIO TA
  • IA_PSPA_19: Implementation of formal quality improvement methods, practice changes, or other practice improvement processes
  • IA_BE_7: Participation in a QCDR, that promotes use of patient engagement tools
  • IA_PSPA_7: Use of QCDR data for ongoing practice assessment and improvements
  • IA_BMH_10: Completion of Collaborative Care Management Training Program
Removed
  • IA_PM_1: Participation in Systematic Anticoagulation Program
  • IA_CC_3: Implementation of additional activity as a result of TA for improving care coordination
  • IA_PSPA_14: Participation in Quality Improvement Initiatives
  • IA_PSPA_5: Annual Registration in the Prescription Drug Monitoring Program
  • IA_PSPA_24: Initiate CDC Training on Antibiotic Stewardship
  • IA_BMH_3: Unhealthy alcohol use
  • IA_BE_11: Participation in a QCDR, that promotes use of processes and tools that engage patients for adherence to treatment plan
  • IA_BE_2: Use of QCDR to support clinical decision making
  • IA_BE_9: Use of QCDR patient experience data to inform and advance improvements in beneficiary
  • IA_BE_10: Participation in a QCDR, that promotes implementation of patient self-action plans
  • IA_CC_6: Use of QCDR to promote standard practices, tools and processes in practice for improvement in care coordination
  • IA_AHE_4: Leveraging a QCDR for use of standard questionnaires
  • IA_AHE_2: Leveraging a QCDR to standardize processes for screening
  • IA_PM_10: Use of QCDR data for quality improvement such as comparative analysis reports across patient populations
  • IA_CC_4: TCPI Participation

Previously, a group or virtual group could attest to an improvement activity if at least one clinician in the group participated in the activity. In 2020, in order for a group or virtual group to attest to an improvement activity, at least 50% of the clinicians in the group or virtual group must perform the same activity during any continuous 90-day period in the performance year.

CMS has also made a technical correction to the definition of ‘Rural Area’ that will not change how rural clinicians are identified.

Also modified are the requirements for patient-centered medical home (PCMH) designation. CMS has removed specific examples of entity names of accreditation organizations in order to remove barriers to designation.

Promoting Interoperability

Currently, hospital-based clinicians who choose to report as a group or virtual group are eligible for reweighting when 100% of the MIPS-eligible clinicians in the group meet the definition of a hospital-based MIPS eligible clinician. In the next performance year, these clinicians are eligible for reweighting when more than 75% of the NPIs in the group or virtual group meet the definition of a hospital-based MIPS eligible clinician.

MIPS Performance Year 2021

Although there are no major changes to the program for 2020, bigger changes are expected in performance year 2021. Subscribe to our MIPS newsletter to stay up to date on these future changes.

November 5th, 2019 Categories: featured, MIPS Information

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CMS Proposes New Measure Specialty Sets, MIPS Value Pathways

What are MIPS value pathways


The final rule for MIPS 2020 outlines the changes to the MIPS program coming in 2021. Read more here.

This week, CMS released the proposed rule for Year 4 of the Quality Payment Program (QPP). Many of the Year 3 requirements will be maintained going into the 2020 performance year; we highlighted the proposed changes in our blog post here. However, there are bigger proposed changes in store for Year 5 of the QPP starting in 2021.

In the latest release, CMS expressed an intention to move toward what they say would be a more streamlined MIPS program. To fulfill upon this vision, the agency is aiming to reduce reported complexities with data submission and confusion surrounding measure selection with a new framework they are calling MIPS Value Pathways (MVPs).

Check out key takeaways below from the proposed rule on MVPs and what CMS has put forth as a very loose framework for the future of the program.

CMS is soliciting public comment on the proposed rule until September 27, 2019 at 5 PM EST.

MIPS Value Pathways defined

The MVP framework would create sets of measure options that CMS says would be more relevant to clinician scope of practice and meaningful to patient care by connecting MIPS measures across the four performance categories specific to specialty or condition. It would also incorporate a set of administrative claims-based quality measures that focus on population health and provide data and feedback to clinicians. CMS says it intends to use the current MIPS specialty measure sets as a base framework for developing these new MVPs. The agency also indicated they will seek to enhance information provided to patients, with possible exploration of new forms of public reporting.

How does the MVP framework change MIPS?

If implemented, all MIPS-eligible clinicians would no longer choose their measures from a single inventory, but would instead fulfill measures and activities connected to a specialty or condition as a part of an MVP. This means the MIPS program would no longer require the same number of measures or activities for all clinicians.

CMS anticipates that an MVP would use a single benchmark for each measure, and all clinicians and groups in the MVP would be compared against the same standard. It is proposed that scoring policies would be evaluated to ensure scoring across MVPs is equitable, so that clinicians reporting a specific MVP are not unfairly advantaged. The agency says this would eliminate the need for special scoring policies and bonuses to incent selection of high priority or outcome measures, as clinicians would be required to report all measures in the MVP.

Additionally, MVPs will focus on bundling quality measures with existing, related cost measures and improvement activities as CMS sees feasible.

How will MIPS data collection be impacted by MVPs?

It is unclear at this time exactly how clinicians and groups will be expected to report data to satisfy measures under the new MVP framework. CMS says that the current MIPS performance measure collection types will continue to be used to the “extent possible,” creating some uneasiness for clinicians and industry leaders who have invested time and resources in their current reporting mechanisms. CMS is soliciting feedback around data submission mechanisms, particularly QCDRs and their role in the program. The agency maintains that a driving force behind the proposed changes is that the flexibility of the program in years 1-3 resulted in multiple benchmarks for each measure and specialty, hindering the ability of CMS to make meaningful comparisons.

Agency emphasizes patient experience and patient reported outcomes

The proposed rule also emphasized an increased focus on patient reported measures, including patient experience, satisfaction and outcomes in their performance measurement. The agency anticipates the MVP framework will provide more meaningful information to patients, which will enable them to make decisions about their care and achieve better outcomes.

CMS Example of Possible MIPS Value Pathway
MVP Example Quality Measures Cost Measures Improvement Activities Promoting Ineroperability
Preventive Health
  • Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (Quality ID: 226)
  • Osteoarthritis: Function and Pain Assessment (Quality ID: 109) Adult Immunization Status, proposed (Quality ID: TBD)
  • Controlling High Blood Pressure (Quality ID: 236)
  • PLUS: population health administrative claims quality measures (e.g., allcause hospital readmission)
  • Total Per Capita Cost (TPCC_1)
  • Medicare Spending Per Beneficiary (MSPB_1)
  • Chronic Care and Preventive Care for Empaneled Patients (IA_PM_13)
  • Engage patients and families to guide improvement in the system of care (IA_BE_14)
  • Collection and use of patient experience and satisfaction data on access (IA_EPA_3)
  • All measures in Promoting Interoperability***

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August 1st, 2019 Categories: featured, MIPS Information, Patient Experience

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CMS Releases 2020 MIPS Proposed Rule


CMS has released the final rule for MIPS 2020. Read the key takeaways here.

If you’re participating in MIPS, you’ll need to know about the changes to the program in 2020. This week, CMS released the Quality Payment Program proposed rule for the next performance year. While their goal is to maintain many of the requirements from the 2019 performance year, there are some updates to the MIPS track. Here are the highlights of the proposed changes.

Quality and Cost performance category weights

In 2020, the Quality performance category weight will be reduced from 45 percent to 40 percent. The Cost category weight will increase from 15 percent to 20 percent.

Payment adjustment

The maximum negative payment adjustment will increase from -7% to -9% in 2020. Positive payment adjustments (not including exceptional performance) will increase from 7% to up to 9%.

Performance threshold

The performance threshold–the minimum number of points to avoid a negative payment adjustment–will increase from 30 points in 2019 to 45 points in 2020. The exceptional performance threshold, which determines additional positive payment adjustments, will increase to 80 points in 2020.

A full breakdown of proposed MIPS changes can be found in the table below. CMS is accepting feedback on the proposed rule at regulations.gov through September 27, 2019 with the file code CMS-1715-P.

CMS has also proposed larger changes to the program starting in 2021. Click here to read our summary of their new proposed framework.

For more information on the current MIPS performance year and how SurveyVitals can help you fulfill your requirements, visit our MIPS page or chat with us using the blue chat icon below.

Policy Area Current Year 3 (Final Rule CY 2019) Year 4 (Proposed Rule CY 2020)
Performance Category Weights
  • Quality: 45%
  • Cost: 15%
  • Promoting Interoperability: 25%
  • Improvement Activities: 15%
  • Quality: 40%
  • Cost: 20%
  • Promoting Interoperability: 25%
  • Improvement Activities: 15%
Quality Performance Category Data Completeness Requirements
  • Medicare Part B Claims measures: 60% of Medicare Part B patients for the performance period
  • QCDR measures, MIPS CQMs, and eCQMs: 60% of clinician’s or group’s patients across all payers for the performance period
Call for Measures
CMS seeks measures that are:
  • Applicable
  • Feasible
  • Reliable
  • Valid at the individual clinician level
  • Different from existing measures
Measure Removal
  • A quality measure may be considered for removal if the measure is no longer meaningful, such as measures that are topped out
  • A measure would be considered for removal if a measure steward is no longer able to maintain the quality measure
QCDR Measure Requirements
  • QCDR measures must be beyond the measure concept phase of development
  • CMS will show a preference for QCDR measures that are outcome-based rather than clinical process measures
  • Measures should address significant variation in performance
  • QCDR measures are approved for use in MIPS for a single performance period
Measure Removal
There is no formal policy for measure removal, as QCDR measures must be submitted for CMS approval on an annual basis as part of the self-nomination process.
Data Completeness Requirements
  • Medicare Part B claims measures: 70% sample of Medicare Part B patients for the performance period
  • QCDR measures, MIPS CQMs, and eCQMs: 70% sample of clinician’s or group’s patients across all payers for the performance period
  • Note: If quality data is submitted selectively such that the data are unrepresentative of a MIPS eligible clinician or group’s performance, any such adat would not be true, accurate, or complete
Call for Measures
In addition to current requirements:
  • Measures submitted in response to Call for Measures would be required to demonstrate a link to existing and related cost measures and improvement activities as appropriate and feasible
Measure Removal
In addition to current measure removal criteria:
  • MIPS quality measures that do not meet case minimum and reporting volumes required for benchmarking for 2 consecutive years would be removed
  • We may consider a MIPS quality measure for removal if we determine it is not available for MIPS Quality reporting by or on behalf of all MIPS eligible clinicians (including via third party intermediaries)
QCDR Measure Requirements
In instances in which multiple, similar QCDR measures exist that warrant approval, we may provisionally approve the individual QCDR measures for 1 year with the condition that QCDRs address certain areas of duplication with other approved QCDR measures in order to be considered for the program in subsequent years. Duplicative QCDR measures would not be approved if QCDRs do not elect to harmonize identified measures as requested by CMS within the allotted timeframe.

QCDR Measure Rejections
CMS is proposing the following guidelines to help QCDRs understand when a QCDR measure would likely be rejected during the annual self-nomination process:

  • QCDR measures that are duplicative of an existing measure or one that has been removed from MIPS or legacy programs
  • Existing QCDR measures that are “topped out” (though these may be resubmitted in future years)
  • QCDR measures that are process-based (consideration given to the impact on the number of measures available for a specific specialty) or have no actionable quality action
  • Considerations and evaluation of the measure’s performance data, to determine whether performance variance exists
  • QCDR measures that have the potential for unintended consequences
  • QCDR measures that split a single clinical practice/action into several measures or that focus on rare events
  • QCDR measures that are “check-box” with no actionable quality action
  • Existing QCDR measures that have been in MIPS for two years and have failed to reach benchmarking thresholds due to low adoption (unless a plan to improve adoption is submitted and approved)
  • Whether the existing approved QCDR measure is no longer considered robust, in instances where new QCDR measures are considered to have a more vigorous quality action, where CMS preference is to include the new QCDR measure rather than requesting QCDR measure harmonization
  • QCDR measures with clinician attribution issues, where the quality action is not under the direct control of the reporting clinician. (that is, the quality aspect being measured cannot be attributed to the clinician or is not under the direct control of the reporting clinician)
  • QCDR measures that focus on rare events or “never events” in the measurement period
Improvement Activities Performance Category Definition of Rural Area
Rural area means a ZIP code designated as rural, using the most recent Health Resources and Services Administration (HRSA) Area Health Resource File data set available.

Patient-Centered Medical Home Criteria
To be eligible for Patient-Centered Medical Home designation, the practice must meet one of the following criteria:

  • The practice has received accreditation from one of four accreditation organizations that are nationally recognized:
    • The Accreditation Association for Ambulatory Healthcare
    • The National Committee for Quality Assurance (NCQA)
    • The Joint Commission
    • The Utilization Review Accreditation Commission (URAC); OR
  • The practice is participating in a Medicaid Medical Home Model or Medical Home Model; OR
  • The practice is a comparable specialty practice that has received the NCQA Patient Centered Specialty Recognition
Improvement Activities Inventory
  • Added 1 new criterion, “Include a public health emergency as determined by the Secretary”
  • Removed “Activities that may be considered for a Promoting Interoperability bonus”
CMS Study on Factors Associated with Reporting Quality Measures
MIPS eligible clinicians who successfully participate in the study receive full credit in the Improvement Activities performance category.

Removal of Improvement Activities
No formal policy but invited public comments on what criteria should be used to identify improvement activities for removal from the inventory.

Requirement for Improvement Activity Credit for Groups
Group or virtual group can attest to an improvement activity if at least one clinician in the TIN participates.

Definition of Rural Area
Rural area is proposed to mean a ZIP code designated as rural by the Federal Office of Rural Health Policy (FORHP) using the most recent FORHP Eligible ZIP Code file available.

Patient-Centered Medical Home Criteria
To be eligible for Patient-Centered Medical Home designation, the practice would need to meet one of the following criteria:

  • The practice has received accreditation from an accreditation organization that is nationally recognized
  • The practice is participating in a Medicaid Medical Home Model or Medical Home Model
  • The practice is a comparable specialty practice that has received recognition through a specialty recognition program offered through a nationally recognized accreditation organization; OR The practice has received accreditation from other certifying bodies that have certified a large number of medical organizations and meet national guidelines, as determined by the Secretary. The Secretary must determine that these certifying bodies must have 500 or more certified member practices, and require practices to include the following:
    1. Have a personal physician/clinician in a team-based practice
    2. Have a whole-person orientation
    3. Provide coordination or integrated care
    4. Focus on quality and safety
    5. Provide enhanced access
Improvement Activities Inventory
  • Addition of 2 new Improvement Activities
  • Modification of 7 existing Improvement Activities
  • Removal of 15 existing Improvement Activities

Please review Appendix 2 in the CY 2020 NPRM for a comprehensive look at the changes proposed to the inventory.

CMS Study on Factors Associated with Reporting Quality Measures
Study year 2019 (CY 2019) is the last year of the 3-year study, as stated in CY 2019 PFS final rule (83 FR 59776). CMS will not continue the study during the 2020 performance period. Final study results will be shared at a later date.

Removal of Improvement Activities
Establish factors to consider for removal of improvement activities from the Inventory. An activity would be considered for removal if:

  • It is duplicative of another activity
  • An alternative activity exists with stronger relationship to quality care or improvements in clinical practice
  • The activity does not align with current clinical guidelines or practice
  • The activity does not align with at least one meaningful measures area
  • The activity does not align with Quality, Cost, or Promoting Interoperability performance categories
  • There have been no attestations of the activity for 3 consecutive years
  • The activity is obsolete
Requirement for Improvement Activity Credit for Groups
  • Group or virtual group would be able to attest to an improvement activity when at least 50% of MIPS eligible clinicians (in the group or virtual group) participate in or perform the activity
  • At least 50% of a group’s NPIs must perform the same activity for the same continuous 90 days in the performance period
Promoting Interoperability Performance Category – Hospital-Based MIPS Eligible Clinicians in Groups

A group is identified as hospital-based and eligible for reweighting when 100% of the MIPS eligible clinicians in the group meet the definition of a hospital-based MIPS eligible clinician.

A group would be identified as hospital-based and eligible for reweighting if more than 75% of the NPIs in the group meet the definition of a hospital-based individual MIPS eligible clinician.

For non-patient facing groups (more than 75% of the MIPS-eligible clinicians in the group are classified as non-patient facing) we would automatically reweight the Promoting Interoperability performance category.

No change to definition of an individual hospital-based MIPS eligible clinician.

Promoting Interoperability Performance Category Objectives and Measures
  • One set of objectives and measures based on the 2015 Edition CEHRT
  • Four objectives: ePrescribing, Health Information Exchange, Provider to Patient Exchange, and Public Health and Clinical Data Exchange
  • Clinicians are required to report certain measures from each of the four objectives, unless an exclusion is claimed
  • PTwo new measures for the e-Prescribing objective: Query of Prescription Drug Monitoring Program (PDMP) and Verify Opioid Treatment Agreement as optional with bonus points available
Objectives and Measures
  • CMS would require a yes/no response for the Query of PDMP measure
  • CMS would redistribute the points for the Support Electronic Referral Loops by Sending Health Information measure to the Provide Patients Access to Their Health Information measure if an exclusion is claimed
Cost Performance Category Measures
  • Total Per Capita Cost (TPCC)
  • Medicare Spending Per Beneficiary (MSPB)
  • 8 episode-based measures
Case Minimums
  • 10 for procedural episodes
  • 20 for acute inpatient medical condition episodes
Measure Attribution
  • All measures are attributed at the TIN/NPI level for both individuals and groups
  • Plurality of primary care services rendered by the clinician to determine attribution for the total per capita cost measure
  • Plurality of Part B services billed during the index admission to determine attribution for the MSPB measure
  • For procedural episodes, we attribute episodes to each MIPS eligible clinician who renders a trigger service (identified by HCPCS/CPT procedure codes)
  • For acute inpatient medical condition episodes, we attribute episodes to each MIPS eligible clinician who bills inpatient evaluation and management (E&M) claim lines during a trigger inpatient hospitalization under a TIN that renders at least 30% of the inpatient E&M claim lines in that hospitalization
Measures
  • TPCC measure (Revised)
  • MSPB-C (MSPB Clinician) measure (Name and specification Revised)
  • 8 existing episode-based measures
  • 10 new episode-based measures
Case Minimums
No changes.

Measure Attribution
  • Measure attribution would be different for individuals and groups and would be defined in the measure specifications
  • TPCC attribution would require E&M services to have an associated primary care service or a follow up E&M service from the same clinician group
  • TPCC attribution would exclude certain clinicians who primarily deliver certain non-primary care services (e.g. general surgery)
  • MSPB clinician attribution changes would have a different methodology for surgical and medical patients
  • No changes proposed for attribution in episode-based measures (existing and new)
Final Score Calculation: Performance Category Reweighting due to Data Integrity Issues
  • No policy to account for data integrity concerns
  • Several scenarios for reweighting have previously been finalized, including extreme and uncontrollable events (all performance categories) and hardship exemptions specific to the Promoting Interoperability performance category
  • We would reweight performance categories in rare events due to compromised data outside the control of the MIPS eligible clinician. MIPS eligible clinicians or third party intermediaries can inform CMS that they believe they are impacted by a relevant event by providing information on the event (CMS may also independently learn of qualifying events)
  • If we determine that reweighting for compromised data is appropriate, we would generally redistribute to the Promoting Interoperability performance category as well as the Quality performance category
  • In rare cases, we would redistribute to the Cost performance category
Performance Threshold / Additional Performance Threshold / Payment Adjustment
  • Performance Threshold is set at 30 points
  • Additional performance threshold set at 75 points for exceptional performance
  • As required by statute, the maximum negative payment adjustment is – 7%
  • Positive payment adjustments can be up to 7% (not including additional positive payment adjustments for exceptional performance) but are multiplied by a scaling factor to achieve budget neutrality, which could result in an adjustment above or below 7%
  • Performance Threshold would be set at 45 points
  • Additional performance threshold would be set at 80 points for exceptional performance
  • As required by statute, the maximum negative payment adjustment is -9%
  • Positive payment adjustments can be up to 9% (not including additional positive adjustments for exceptional performance) but are multiplied by a scaling factor to achieve budget neutrality, which could result in an adjustment above or below 9%
Targeted Review

MIPS eligible clinicians and groups may submit a targeted review request by September 30 following the release of the MIPS payment adjustment factor(s) with performance feedback.

All requests for targeted review would be required to be submitted within 60 days of the release of the MIPS payment adjustment factor(s) with performance feedback.

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July 30th, 2019 Categories: featured, MIPS Information, Patient Experience

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MACRA Quality Payment Program: MIPS 2020

The Quality Payment Program (QPP) falls under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). It is a value-based program that determines reimbursement for clinicians treating Medicare patients.

The Centers for Medicare and Medicaid Services (CMS) recently released the final rule outlining the Quality Payment Program (QPP) for 2020. Keep reading to learn how the changes could affect you, and how SurveyVitals can help your organization meet reporting requirements.

Who Participates?

If you bill Medicare Part B more than $90,000 in allowed charges per year and provide over 200 covered professional services under the Physician Fee Schedule for more than 200 unique Medicare patients a year, then you are part of the QPP. If you do not meet all three criteria, you could be exempt from participating in the program in 2019 under the the low-volume threshold exemption. Beginning in 2019, clinicians who meet the low-volume threshold may still opt in to MIPS if they meet at least one criterion.

Eligible clinicians under the program include:
  • Physicians
  • Physician assistants
  • Nurse practitioners
  • Clinical nurse specialists
  • Certified registered nurse anesthetists
  • Physical therapists
  • Occupational therapists
  • Qualified speech-language pathologists
  • Qualified audiologists
  • Clinical psychologists
  • Registered dietitian or nutrition professionals

If you are unsure if you are required to participate in MIPS, CMS has provided a resource to check your status by entering your NPI into an eligibility “calculator.” Additionally, the agency plans to send letters to clinicians notifying them of their eligibility in 2020.

MIPS Eligibility

Two Tracks: Which is right for you?

There are two participation tracks in the Quality Payment Program. Most Medicare Part B clinicians and groups will fall under the Merit Incentive Payment System (MIPS) track, while a smaller percentage will qualify to participate in the Advanced Alternative Payment Models (APM) track if considered an “advanced APM.” It is important to note that those APM models which are not considered “advanced” by CMS will still participate in the MIPS track.

Learn more about APMs here.

The MIPS Track

You will receive a performance-based adjustment to your Medicare fee schedule in 2022 based on your performance in 2020. The amount of the adjustment, either positive, negative, or neutral, is based on an eligible clinician or group’s Composite Performance Score (CPS). The CPS is calculated using data across four categories of measurement:

  1. Quality
  2. Promoting Interoperability
  3. Improvement Activities
  4. Cost

MIPS Category Weights

How do I avoid a negative payment adjustment?

For the 2020 performance year, CMS extended a portion of the “pick your pace” program, allowing clinicians to submit just 90 consecutive days of performance data for the required measures in the Improvement Activities and Promoting Interoperability categories. However, clinicians will need to report data on all required measures in the Quality category for the full performance year (12 months).

CMS will also score and measure the Cost category for the full 12 month period as well. Since CMS gathers the Cost category information through Medicare claims data, no additional submission mechanism is required. If you do not participate in MIPS in 2020 you could be faced with a 9% penalty.

MIPS Performance Periods

Individual vs. Group Reporting

Eligible clinicians have the option to report as an individual, within a group, or within a virtual group.

An individual is a single National Provider Identifier, or NPI, tied to a single Taxpayer Identification Number, or TIN.

A group is a single TIN with two or more eligible clinicians (including at least one MIPS eligible clinician), as identified by their NPIs, who have reassigned their Medicare billing rights to the TIN. Participants are scored as a group and receive one payment adjustment based on aggregate performance.

A virtual group is a combination of two or more TINs assigned to one or more solo practitioners or one or more groups consisting of ten or fewer eligible clinicians that elect to form a virtual group for a performance period for a year. There is currently no limit on the number of TINs that can participate in a virtual group. Virtual Groups bring additional flexibility to the program, allowing clinicians to participate in MIPS with their peers, regardless of their geographical proximity or specialty. Those wishing to participate in a MIPS Virtual Group must make a formal election with CMS by December 31, 2019.

MIPS Individual and Group Reporting

Data for participants can be reported by various submission types by an individual or group as applicable. Alternatively, data may be reported by a Third Party Intermediary that submits data on measures and activities on behalf of a MIPS eligible clinician or group.

Selecting and Reporting Measures

The aim of the MIPS program is to provide clinicians and groups with the flexibility to select measures that best suit their practice. For the Quality category, participants can choose from several types of measures, which vary based on whether they are reporting as individuals or as part of a group. Submission methods are dependent on the types of measures chosen.

MIPS Data Collection

For the Improvement Activities and Promoting Interoperability categories, participants choose their measures from the QPP website. There are three submission methods for these measures.

  1. Direct: Users transmit data through a computer-to-computer interaction such as an API.
  2. Log-in and upload: Users log in with a set of authenticated credentials and upload and submit data in a CMS-specified format.
  3. Log-in and attest: Users log in with a set of authenticated credentials and manually attest that certain measures and activities were performed.

MIPS Requirements

Quality Category

Eligible clinicians are required to report six measures of their choosing for the Quality category. One of those measures must be an outcome measure. If no outcome measure is available, a ‘high priority’ measure must be reported in its place. High priority measures are contained in the following domains: outcome, appropriate use, patient safety, efficiency, patient experience, efficiency, and care coordination.

What are specialty measurement sets?

CMS developed specialty measure sets as a part of the available MIPS measures in the Quality Category. Participating clinicians must choose six measures to report within their specialty set. If there are fewer than six Quality measures to choose from in a specialty set, the clinician or group must complete all available measures contained in the set.

For anesthesia clients

SurveyVitals can help anesthesia clients who utilize a Qualified Clinical Data Registry (QCDR) meet a measure–AQI 48 (anesthesia patient experience)–in the Quality performance category. Learn more here.

Improvement Activities

The IA category requires clinicians to participate in a combination of measures totaling 40 points to fully satisfy reporting requirements. Activities weighted “high” are worth 20 points, while “medium” weighted activities are valued at ten points. Clinicians and groups considered non-patient facing, and practices with 15 or fewer eligible providers and/or clinicians practicing in rural and health professional shortage areas, may face reduced reporting requirements. Learn more about these special exemption statuses here.

MIPS Improvement Activities

In order for a group or virtual group to attest to an improvement activity, at least 50% of the clinicians in the group or virtual group must perform the same activity during any continuous 90-day period in the performance year.

Your SurveyVitals solution can help you satisfy measures in the IA category. Download our “Roadmap to Improvement Activities” or contact us at info@surveyvitals.com to learn more.

Promoting Interoperability

The Promoting Interoperability category places an emphasis on interoperability and patient engagement with certified EHR technology. Eligible clinicians must report on certain measures from four ‘objectives,’ or claims exclusions if applicable. Scoring is performance-based at the individual measure level, for a total of up to 100 points. In 2020, organizations must use the 2015 Edition CEHRT.

Special Status

Clinicians and groups considered non-patient facing, and practices with 15 or fewer eligible providers and/or clinicians practicing in rural and health professional shortage areas, may face reduced reporting requirements. Watch the video below to learn more.

Anesthesia QCDR Reporting

SurveyVitals can help anesthesia clients who utilize a Qualified Clinical Data Registry (QCDR) meet a measure–AQI 48 (anesthesia patient experience)–in the Quality performance category. We currently support NACOR (Anesthesia Quality Institute), Anesthesia Business Group, Anesthesia Quality Registry (ePreop), and Medaxion. Learn more here.

What are the current MIPS dates and deadlines?

December 31, 2019

Last day to make a virtual group election for the 2020 performance year

January 1, 2020

2020 performance year begins

January 2, 2020

Data submission period for the 2019 performance year begins

March 31, 2020

Data submission for the 2019 performance year closes

October 3, 2020

Last day to begin the continuous 90-day performance period for Improvement Activities

December 31, 2020

2020 performance year ends

How is MIPS different in 2020?

To learn about the changes from year 3 (2019) to year 4 (2020) of the MIPS program, see our article on the 2020 updates.

Does SurveyVitals administer CAHPS for MIPS?

Yes! SurveyVitals is a CMS-approved vendor ready to administer CAHPS for MIPS on behalf of your organization in 2019. The CAHPS for MIPS survey can be used to satisfy one Quality measure or one Improvement Activity.

Contact us at info@surveyvitals.com to learn more about our CAHPS program.

Interested in meeting measures with SurveyVitals?

Want to learn how SurveyVitals can help you prepare for MIPS? Subscribe to our MIPS update list below or email us at support@surveyvitals.com. You can also send us a message using the blue chat icon below to speak to a member of our support team.

*Note: Information and program details are based solely upon SurveyVitals’ experience with MACRA and our interpretation of CMS rule-making and policy statements. The information presented does not reflect the views or policies of CMS or any other governmental agency and is not to be construed as practice management advice.

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March 13th, 2019 Categories: Ambulatory and Outpatient Surgery, Anesthesia, CAHPS Surveys, Emergency Medicine, featured, MIPS Information, Neonatology, Outpatient Practice, Radiology, Urgent Care

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MIPS 101 for Anesthesia Providers

MIPS anesthesiologist
***Updated January 2020***

Are you an anesthesia provider participating in the Merit-Based Incentive Payment System (MIPS)? Let us tell you how the SurveyVitals solution might help you fulfill certain reporting requirements.

What is MIPS?

The Merit Incentive Payment System (MIPS) is one of two tracks in the QPP, the quality payment incentive program implemented by CMS. A small percentage of clinicians will qualify to participate in the Alternative Payment Models (APM) track, but most anesthesiologists will fall under the MIPS track.

You will receive a performance-based adjustment to your Medicare fee schedule in 2022 based on your MIPS performance in 2020. The amount of the adjustment, either positive, negative, or neutral, is based on an eligible clinician or group’s Composite Performance Score (CPS). The CPS is calculated using data across four categories of measurement.

Who participates?

If you bill Medicare Part B more than $90,000 in allowed charges per year and provide over 200 covered professional services under the Physician Fee Schedule for more than 200 unique Medicare patients a year, then you are part of the QPP. If you do not meet all three criteria, you could be exempt from participating in the program in 2020 under the the low-volume threshold exemption. Clinicians who meet the low-volume threshold may still opt in to MIPS if they meet at least one criterion.

To determine if you are required to participate in MIPS, CMS has provided a resource to check your status by entering your NPI into an eligibility “calculator.”

How are measures reported?

Anesthesiologists have the option to report as an individual, within a group, or within a virtual group.

Individual Single NPI tied to a single Tax Identification Number (TIN)
Group Single TIN with two or more eligible clinicians, including at least one MIPS-eligible clinician, as identified by their National Provider Identifiers (NPIs), who have reassigned their Medicare billing rights to the TIN
Virtual Group Combination of two or more TINs assigned to one or more solo practitioners or one or more groups consisting of ten or fewer eligible clinicians

Reporting mechanisms vary based on reporting type and measure category. You can find more information on reporting mechanisms here.

How are measures selected?

Anesthesia providers and groups can select measures from the list of CMS-approved MIPS measures at the QPP website. Alternatively, they may select to report on Quality performance using specialized measures developed by a Qualified Clinical Data Registry (QCDR) of their choosing. QCDR measures must be approved each year by CMS.

Quality Category

Anesthesiologists are required to report on six measures of their choosing for the quality category. One of those measures must be an outcome measure.

SurveyVitals is equipped to help anesthesia clients utilizing a QCDR to meet an outcome measure (AQI 48 – Patient-Reported Experience with Anesthesia) in the Quality category. You must sign a disclaimer in order to report your patient experience data to a QCDR. View the reporting checklist, quick facts, and important deadlines here.

Improvement Activities (IA) Category

Anesthesia providers are required to participate in a combination of IA measures totaling 40 points. “High-weighted” activities are worth 20 points, while “medium-weighted” activities are valued at ten points. Your SurveyVitals solution can help you satisfy measures in the IA category. Download our “Road-Map to Improvement Activities” or contact us at info@surveyvitals.com to learn more.

In order for a group or virtual group to attest to an improvement activity, at least 50% of the clinicians in the group or virtual group must perform the same activity during any continuous 90-day period in the performance year.

Reporting requirements for Improvement Activities are reduced for non-patient facing clinicians, which are defined as either:

  • An individual clinician that bills 100 or fewer patient-facing encounters (including Medicare telehealth services), or
  • A group that provided more than 75 percent of the clinician’s billing under the group’s TIN

Those considered non-patient facing must participate in one high-weighted activity or two medium-weighted activities to satisfy the Improvement Activities category (for a total of 20 points rather than 40).

Always remember to check the eligibility calculator on the QPP website to confirm you are considered non-patient facing.

Promoting Interoperability Category

The Promoting Interoperability category places an emphasis on interoperability and patient engagement with certified EHR technology. Eligible clinicians must report on certain measures from four ‘objectives,’ or claims exclusions if applicable. Scoring is performance-based at the individual measure level, for a total of up to 100 points. In 2020, organizations must use the 2015 Edition CEHRT.

Cost Category

The score for the Cost category is calculated using administrative claims data. No data submission is required.

How can SurveyVitals help you succeed with MIPS?

SurveyVitals can help you meet one Quality measure and fulfill the entire Improvement Activities category. Reference the table below to see which measures we can help you meet.

MIPS Category Measures We Support More Information
Quality AQI 48 (Outcome) Anesthesia QCDR Reporting
Improvement Activities High-weighted:
  • IA_BE_6
  • IA_PSPA_11
Medium-weighted:
  • IA_BE_13
  • IA_PSPA_4
  • IA_PSPA_18
  • IA_PSPA_19
  • IA_PSPA_20
Improvement Activities Roadmap

Want to learn how SurveyVitals can help you prepare for MIPS? Email us at support@surveyvitals.com. You can also send us a message using the blue chat icon below to speak to a member of our support team.

Learn More!

*Note: Information and program details are based solely upon SurveyVitals’ experience with MACRA and our interpretation of CMS rule-making and policy statements. The information presented does not reflect the views or policies of CMS or any other governmental agency and is not to be construed as practice management advice.

June 3rd, 2018 Categories: Anesthesia, MIPS Information

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