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

CMS Proposes New Measure Specialty Sets, 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***

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

Tags: CMS, improvement activities, macra, MIPS, QCDR, QPP, Quality, quality category, quality payment program

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: Have a personal physician/clinician in a team-based practice Have a whole-person orientation Provide coordination or integrated care Focus on quality and safety 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.

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

Tags: Improvement, improvement activities, macra, MIPS, patient experience, QCDR, QPP, Quality, quality category, quality payment program

MACRA Quality Payment Program: MIPS 2022

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 2022. Keep reading to learn how the changes could affect you, and how SurveyVitals can help your organization meet reporting requirements.

Two Tracks: Which is right for you? The MIPS Track How do I avoid a negative payment adjustment? Individual vs. Group Reporting Selecting and Reporting Measures Quality Category Improvement Activities Promoting Interoperability Special Status Anesthesia QCDR Reporting What are the current MIPS dates and deadlines? How is MIPS different in 2022? Does SurveyVitals administer CAHPS for MIPS? Interested in meeting measures with SurveyVitals?

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 2022 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.

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
Certified nurse midwives
Clinical social workers

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 2022.

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 2024 based on your performance in 2022. 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:

Quality
Promoting Interoperability
Improvement Activities
Cost

How do I avoid a negative payment adjustment?

With the “pick your pace” program, clinicians submit just 90 consecutive days of performance data for the required measures in the Improvement Activities and Promoting Interoperability categories. However, clinicians 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 2022 you could be faced with a 9% penalty.

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, 2022.

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.

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

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

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

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.

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 2022, 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, and Anesthesia Quality Registry (Provation). Learn more here.

What are the current MIPS dates and deadlines?

January 1, 2022:2022 performance year begins
January 3, 2022: Data submission period for the 2021 performance year begins
March 31, 2022: Data submission for the 2021 performance year closes
July 2022: CMS provides performance feedback based on submissions for the 2021 performance year
October 3, 2022: Last day to begin the continuous 90-day performance period for Improvement Activities
December 31, 2022: Last day to make a virtual group election for the 2023 performance year
December 31, 2022: 2022 performance year ends
January 1, 2023: Payment adjustments from the 2021 performance year go into effect

How is MIPS different in 2022?

To learn about the changes to the MIPS program from 2021 to 2022, see our article on the 2022 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 2022. The CAHPS for MIPS survey can be used to satisfy one Quality measure or contribute toward one Improvement Activity.

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.

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

Tags: APM, CAHPS, cost category, improvement activities, macra, MIPS, Performance Year, promoting interoperability, QCDR, QPP, quality category, quality payment program

Is GPRO the way to go?

Update: GPRO is a part of the retired PQRS program that has been replaced by MIPS under the Quality Payment Program (QPP). Learn more about MIPS here.

At SurveyVitals, we believe there’s great value in the Qualified Clinical Data Registry (QCDR) quality data reporting option. In 2015, only Eligible Professionals (EPs) can report through a QCDR. Some great news is that CMS recently shared they’re adding a reporting option allowing group practices to report quality measure data using a QCDR for 2016. Please read below for more detail about the differences between GPRO and QCDR.

By now, everyone understands that physicians who don’t report adequate quality measures in 2015 will see a 2% penalty in 2017. There are still questions, however, about the best way to report your quality data to CMS, especially for outpatient practices. And while the date to adjust your 2015 reporting mechanism has passed, we’d like to share some information as you start thinking about your plan for 2016.

At the highest level, you must decide whether to report as an individual EP (Eligible Professionals) or as part of a group. There are pros and cons to each, although SurveyVitals® recommends the individual EP route. Among other reasons, this option allows you to submit quality data through a QCDR (Qualified Clinical Data Registry) if one exists for your specialty.

GPRO, the Group Practice Reporting Option, is another method to submit your quality data, but has numerous CMS requirements. Here are a few things we’d like our clients to know about GPRO for 2015:

GPRO is optional.
GPRO only applies to EPs with a common Tax Identification Number (TIN).
If you chose a GPRO reporting method, the decision is irreversible for 2015 (the deadline was June 30, 2015).
You cannot submit your data through a QCDR if you choose GPRO.*
If you choose GPRO and have 100 or more EPs (25 or more for 2016), you’ll be required to run the CAHPS for PQRS survey. The survey is optional in 2015 for groups of 2-99 EPs.
- Most importantly, the survey is tailored to primary care.
- The survey will not be paid for or administered by CMS. Participating groups will be required to contract with a CMS-certified vendor to administer the CAHPS for PQRS survey.
- The CAHPS for PQRS survey will be administered on paper with live phone follow-ups for non-responders. Surveys sent via email or text message aren’t allowed at this time, which makes improvement based on real-time feedback virtually impossible. This is why SurveyVitals is not a CMS-certified vendor.
- CAHPS for PQRS does count as a measure.

Choosing whether to report quality measures as a group or by individual can be a complicated decision when you factor in eligibility and reporting requirements, and here’s why we recommend individual reporting:

Individual EPs can submit through QCDRs:
- QCDRs can focus on more relevant, specialty-specific quality measures. Now is the time to promote the QCDR concept and its benefits to your specialty board.
- The QCDR collects data for the purpose of providing improved quality of care for patients.
- There is greater potential to meet the reporting requirement of 9 measures across 3 National Quality Strategy domains.
- The QCDR typically submits data to CMS on your behalf.

As we announced earlier this year, our Patient Satisfaction Questionnaires (APSQ, SPSQ, or HSQ), fulfills measures for many QCDRs. We’re working to get a patient satisfaction measure included in other QCDRs for 2016. We expect that the list will continue to grow, so contact us if you’d like additional information on the measures SurveyVitals can help you meet for each QCDR.

If you don’t report through a QCDR, it is still beneficial to report individually since the measures that must be reported to CMS are the same. Although some variations exist in the methods (for 2015, claims-based for individual reporting and web interface for GPRO 25+ EPs), you can avoid the CAHPS for PQRS survey requirement and its expense. Additionally, the Value-Based Payment Modifier (VM) is not affected by reporting individually since the VM is calculated by TIN.

* In late October 2015, CMS released some preliminary information regarding PQRS for 2016. From the CMS website: “CMS makes changes to the PQRS measure set to add measures where gaps exist, as well as to eliminate measures that are topped out, duplicative, or are being replaced with a more robust measure. There will be 281 measures in the PQRS measure set and 18 measures in the GPRO Web Interface for 2016. Also, as recently authorized under MACRA, CMS is adding a reporting option that will allow group practices to report quality measure data using a Qualified Clinical Data Registry (QCDR).

We’ll wait for the final 2016 PQRS webpage to become available (typically by January 1, 2016) to see how this plays out, and SurveyVitals will attempt to stay on top of these ever changing requirements in order to provide the most value to our clients. Stay tuned for more!

blake November 13th, 2015 Categories: CAHPS Surveys, featured, MIPS Information

Tags: CMS, GPRO, PQRS, QCDR

To GPRO, or not to GPRO, that is the question for anesthesiology providers

By now, everyone understands that physicians who don’t report adequate quality measures in 2015 will see a 2% penalty in 2017. There are still questions, however, about the best way to report your quality data to CMS, especially for anesthesiology providers. And while the date to adjust your 2015 reporting mechanism has passed, we’d like to share some information as you start thinking about your plan for 2016.

At the highest level, you must decide whether to report as an individual EP (Eligible Provider) or as part of a group. There are pros and cons to each, although SurveyVitals® recommends the individual EP route. Among other reasons, this option allows you to submit quality data through a QCDR (Qualified Clinical Data Registry).

GPRO, the Group Practice Reporting Option, is another method to submit your quality data, but has numerous CMS requirements. Here are a few things we’d like our clients to know about GPRO:

GPRO is optional.
GPRO only applies to EPs with a common Tax Identification Number (TIN).
If you chose a GPRO reporting method, the decision is irreversible for 2015 (the deadline was June 30, 2015).
You cannot submit your data through a QCDR if you choose GPRO.
If you choose GPRO and have 100 or more EPs (25 or more for 2016), you’ll be required to run the CAHPS for PQRS survey. The survey is optional in 2015 for groups of 2-99 EPs.
- The survey is tailored to primary care, which does not help anesthesiology providers.
- The survey will not be paid for or administered by CMS. Participating groups will be required to contract with a CMS-certified vendor to administer the CAHPS for PQRS survey.
- The CAHPS for PQRS survey will be administered on paper with live phone follow-ups for non-responders. Surveys sent via email or text message aren’t allowed at this time, which makes improvement based on real-time feedback virtually impossible. This is why SurveyVitals is not a CMS-certified vendor.
By reporting via GPRO, you’re agreeing to have your PQRS performance results publicly posted on the Physician Compare website. The performance rates will apply to the entire group.

Individual EPs can submit through QCDRs:
- QCDRs can focus on more relevant, anesthesia-specific quality measures.
- The QCDR collects data for the purpose of providing improved quality of care for patients.
- There is greater potential to meet the reporting requirement of 9 measures across 3 National Quality Strategy domains.
- The QCDR typically submits data to CMS on your behalf.
- As the ASA said on its website, “Participation in [the] ASA QCDR not only helps protect a practice’s income, but it also helps keep money in the practice so you can continue your focus on patient safety.

As we announced earlier this year, our Anesthesia Patient Satisfaction Questionnaire, the APSQ, fulfills measure #16 for NACOR, the Composite Patient Experience, and counts as an outcome measure as well. We’re also working to get a patient satisfaction measure included in other QCDRs like ABG and ASPIRE for 2016. We expect that list will continue to grow, so contact us if you’d like additional information on the measures SurveyVitals can help you meet for each QCDR.

SurveyVitals will attempt to stay on top of these ever changing requirements in order to provide the most value to our clients. Stay tuned for more!

blake October 7th, 2015 Categories: Anesthesia, CAHPS Surveys, featured, MIPS Information

Tags: CMS, GPRO, NACOR, Oct 2015, PQRS, QCDR

Avoid the 2% penalty

An easier, more valuable way to satisfy the PQRS reporting requirement

You’re probably familiar with the burden of PQRS reporting, and know that CMS has instituted a 2% penalty (to be levied in 2017) for group practices and individual EPs (eligible professionals) who do not report adequate quality measures in 2015.

Did you know that it’s not necessary to administer the CAHPS for PQRS (an expensive, 92-question, paper-only survey) if you submit your measures through NACOR, the National Anesthesia Clinical Outcomes Registry?

NACOR, maintained by the Anesthesia Quality Institute (AQI), has been designated as a Qualified Clinical Data Registry (QCDR) by CMS. You’re required to report 9 measures across 3 domains, including 2 outcome measures.

We’re pleased to announce that your SurveyVitals solution fulfills measure #16, the Composite Patient Experience, and counts as an outcome measure as well.

Please contact us if you’d like SurveyVitals to submit your quality data to NACOR on a monthly basis.

Note: This is not an option for GPRO-registered EPs in 2015, but you can opt out of GPRO in 2016 if you choose to submit your data to NACOR in 2016.

More Info on PQRS from the CMS website

PQRS is a reporting program that uses a combination of incentive payments and negative payment adjustments to promote reporting of quality information by EPs.

More Info on QCDR Reporting for 2015

NACOR was approved as a QCDR for the CMS PQRS in 2014. Remember, for 2015, all Eligible Professionals must report on 9 measures (across 3 domains), 2 of which must be outcome measures. Read more.

blake July 13th, 2015 Categories: featured, MIPS Information

Tags: AQI, NACOR, PQRS, QCDR

MIPS Value Pathways

APM Performance Pathway

Performance Category Weights

Performance Threshold

Performance Categories

Quality Category

Improvement Activities Category

Cost Category

COVID-19 Flexibility Scoring Proposals

MIPS and SurveyVitals

MIPS Value Pathways defined

How does the MVP framework change MIPS?

How will MIPS data collection be impacted by MVPs?

Agency emphasizes patient experience and patient reported outcomes

Quality and Cost performance category weights

Payment adjustment

Performance threshold

Be the first to know! Join our MIPS mailing list.

Who Participates?

Two Tracks: Which is right for you?

The MIPS Track

How do I avoid a negative payment adjustment?

Individual vs. Group Reporting

Selecting and Reporting Measures

Quality Category

What are specialty measurement sets?

For anesthesia clients

Improvement Activities

Promoting Interoperability

Special Status

Anesthesia QCDR Reporting

What are the current MIPS dates and deadlines?

How is MIPS different in 2022?

Does SurveyVitals administer CAHPS for MIPS?

Interested in meeting measures with SurveyVitals?

An easier, more valuable way to satisfy the PQRS reporting requirement

More Info on PQRS from the CMS website

More Info on QCDR Reporting for 2015

Recent Posts

Trend: Patients seeking resources on scheduling COVID-19 vaccine in satisfaction surveysMarch 17, 2021

MIPS Improvement Activities Best PracticesMarch 11, 2021

MIPS Extreme & Uncontrollable Circumstances Application ExtendedMarch 5, 2021

Best Practice: Responding to Online ReviewsMarch 3, 2021

Trend: Patients seeking resources on scheduling COVID-19 vaccine in satisfaction surveys
March 17, 2021

MIPS Improvement Activities Best Practices
March 11, 2021

MIPS Extreme & Uncontrollable Circumstances Application Extended
March 5, 2021

Best Practice: Responding to Online Reviews
March 3, 2021