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Dissecting Merit-Based Incentive Payment System Reporting

Eligible clinicians should understand the basics of MIPS reporting, such as how to report and what data to submit, as the data submission deadline approaches.

Merit-Based Incentive Payment System (MIPS) reporting

Source: Thinkstock

By Jacqueline LaPointe

*UPDATE: CMS extended the MIPS reporting deadline to Tuesday, April 3, 2018, at 8:00 pm EDT, according to an email sent on March 29.

Eligible clinicians participating in MACRA’s Merit-Based Incentive Payment System (MIPS) must submit their 2017 performance data by March 31 to avoid a negative payment adjustment in 2019.

The March deadline will mark the first time that qualifying Medicare providers will participate in the programs created by MACRA, which was signed into law in 2015. The historic bill eliminated the Sustainable Growth Rate formula, replacing it with the Quality Payment Program (QPP) and its two payments tracks: MIPS and Advanced Alternative Payment Models (Advanced APMs).

MACRA also phased out and streamlined several Medicare value-based purchasing programs, including the Physician Quality Reporting System (PQRS), Value-Based Payment Modifier, and the Medicare EHR Incentive Program. Elements of the legacy programs can be found in MIPS, but CMS emphasized that the reporting process for the value-based purchasing program is very different.

The following article will explore what eligible clinicians need to know about MIPS reporting for the 2017 performance year to avoid a penalty in 2019.

Web-based QPP reporting system and EIDM accounts

READ MORE: Top 5 Facts About the Merit-Based Incentive Payment System

CMS launched a web-based Quality Payment Program reporting system on the QPP website in January 2018. The federal agency boasted that the new reporting system is a step up from the systems used for legacy value-based purchasing programs, which required participating to providers to submit data on multiple websites.

For the QPP, CMS designed a more convenient option for eligible clinicians by just having them submit 2017 performance data on one website.

“The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires CMS to implement the Quality Payment Program, and we are committed to doing so in the least burdensome way possible,” stated Seema Verma, CMS Administrator. “The new data submission system makes it easier for clinicians to meet MACRA’s reporting requirements and spend more time treating patients instead of filing paperwork.”

Eligible clinicians can find the reporting system on the QPP website in the top right corner of the homepage. Clinicians should log in with an Enterprise Identity Management (EIDM) account to begin submitting performance data to MIPS.

Medicare providers who have submitted data to legacy programs, such as PQRS, will have the same account for the QPP website.

READ MORE: Physician Expert, Clinical Documentation Key to MIPS Success

Eligible clinicians who need an EIDM account or need to access account information should go to the CMS Enterprise Portal, CMS advised in a recent fact sheet.

In addition to an EIDM account, clinicians should also have an appropriate user role associated with their account. The user role should reflect the provider's role in the organization.

Once eligible clinicians have an EIDM account and an appropriate user role, they should sign into the QPP reporting system on the program’s website and start submitting performance data.

Clinicians should be aware that there are no “save” or “submit” buttons in the reporting system. The reporting system has continuous submission, which means data entered into the system will automatically update a clinician’s record.

Eligible clinicians are welcome to update performance data at any time until March 31 and CMS will determine payment adjustments based on the final submission update.

READ MORE: 4 Strategies for Merit-Based Incentive Payment System Success

The reporting system also includes automatic feedback and scoring. For each submission, the system will generate a MIPS performance score. Clinicians can update their data to improve their scores until the data submission deadline.

How to report MIPS performance data

CMS offered eligible clinicians several options on how to report MIPS performance data. Clinicians should first decide whether to report individually or as a group.

Under group participation, clinicians receive one score based on the group’s performance in MIPS, the fact sheet explained. Clinicians can attest to MIPS as a group if:

• Two or more clinicians are in the group

• At least one clinician is eligible for MIPS

• All the eligible clinicians bill Medicare through a single Taxpayer Identification Number (TIN) regardless of specialty or practice site

CMS noted that geographic location of eligible clinicians is irrelevant as long as the clinicians use the same TIN.

Clinicians can switch between reporting as an individual or a group until the March 31 deadline.

“Even if you choose one method to start, you can always switch to the other,” CMS stated in the fact sheet. “We’ll retain all submitted data in our system and calculate an eligible clinician’s score (and MIPS payment adjustment) using the data that results in the higher score.”

Reporting as an individual or a group will determine the reporting mechanisms available for MIPS reporting, according to the QPP website.

For clinicians reporting individually, they will be able to report MIPS data using qualified clinical data registries (QCDRs), qualified registries, EHRs, administrative claims, and attestation. They can also report quality measures using the routine Medicare claims process.

Groups have a couple more options for MIPS reporting. In addition to QCDRs, qualified registries, EHRs, and attestation, groups can also use the CMS Web Interface (only available to groups with 25 or more eligible clinicians) and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS survey (only available to groups with two or more eligible clinicians).

CMS noted that the CMS Web Interface and CAHPS for MIPS survey do require registration prior to using the mechanisms as MIPS reporting tools.

Clinicians should also be aware that reporting mechanisms also depend on performance category. For example, individual clinicians can only use claims, EHRs, QCDRs, and qualified registries to submit quality data to MIPS, while attestation, EHRs, QCRDs, and qualified registries are the only options for Improvement Activities and Advancing Care Information.

Chart shows MIPS reporting mechanisms by reporting type and performance category.

Source: CMS

Similar restrictions exist for clinicians reporting as a group to MIPS.

Reporting on Quality, Improvement Activities and Advancing Care Information

MIPS contains four performance categories: cost, quality, Improvement Activities, and Advancing Care Information.

While CMS designed the program to account for cost performance in MIPS, the performance category will not affect MIPS performance scores for the 2017 period. 2017 served as a transition year and reporting requirements are lower.

“The rationale behind this was to really have clinicians understand what cost measurement is. It’s a relatively new concept for providers,” explained Reena Duseja, MD, CMS Director for the Division of Quality Measurement. “We also eliminated the cost category’s weight in 2017 to really get as much feedback as we can get from the community and stakeholders as we’re developing the measures.”

Eligible clinicians may not have to worry about their cost performance in 2017, but they will need to submit data on measures for the other categories to avoid a penalty in 2019. Under the transition year in 2017, submitting information on one quality measure or one Improvement Activity or four or five required Advancing Care Information measures will prevent a negative payment adjustment.

Image shows minimum MIPS reporting requirements in 2017.

Source: CMS

For the first MIPS performance period, eligible clinicians can submit performance data on at least one quality measure to prevent a negative payment adjustment. Although, submitting more performance data could result in positive payment adjustments.

Eligible clinicians can choose between one and six measures from over 271 quality measures under MIPS. But clinicians should select measures on which they know they already perform well, advised Ida Mantashi, CMHP, Chair of the Quality Measurement Workgroup at HIMSS Electronic Health Record Association.

“Now some of the EHRs and the dashboards show which measures the providers are doing better on,” she said. “We do recommend them to stay with that selection. Select the top six that they’re doing much better on and don’t forget about outcome measures and high-priority ones.”

Clinicians aiming to fully participate in MIPS this year should report on at least one outcome measure to earn full points for quality.

Eligible clinicians can also report performance data on Improvement Activities and/or Advancing Care Information to earn positive payment adjustments.

Improvement Activities include measures that assess care coordination, beneficiary engagement, and patient safety. For full MIPS participation for the 2017 performance year, eligible clinicians must report on four medium-weighted, two high-weighted, or one high-weighted and two medium-weighted Improvement Activities for a minimum of 90 days.

The QPP website currently lists 93 approved activities, including anticoagulant management improvement, community engagement for health status improvement, and implementation of medication management practice improvements.

The Advancing Care Information category replaced the Medicare meaningful use initiative for clinicians and includes measure related to health IT and EHR use.

For 2017, CMS created two measure set options for reporting on Advancing Care Information. The first option is the Advancing Care Information Objectives and Measures set. Eligible clinicians can report on this measure set if their certified EHR is the 2015 edition or they use a combination of 2014 and 2015 editions that can support the measures.

Eligible clinicians with 2014, 2015, or a combination of editions can report on the second measure set option, known as the 2017 Advancing Care Information Transition Objectives and Measures.

Following the MIPS reporting process and submitting accurate, complete data is key to preventing Medicare reimbursement from dropping in the near future. Eligible clinicians should prioritize MIPS reporting as the deadline approaches to maximize their positive payment adjustments.

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