In this episode Dr. Dan Mingle answers listener questions about using QDC codes for APM Performance Pathway (APP) reporting, MIPS results for the 2022 performance year, MIPS measure options for ophthalmologists, and more.

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Question One: 2022 MIPS Results

Maryellen asks: “MIPS Scores have been released for the 2022 Performance Year. What do we know so far?”

On or about August 10th, 2023, Medicare released MIPS results for the 2022 performance year, which will determine MIPS adjustments in the 2024 payment year.

Scores are initially released only for review by the providers and groups to which or to whom they pertain.

It is essential to review your scores and request a targeted review if you believe an error exists.

You can access your scores on the Quality Payment Program website. You will need to sign in with your QPP credentials. If you don’t have credentials, you will be directed to the HARP system to prove your identity and to create an account.

Once you can access your scores, you can also access an electronic form to request a targeted review. If you need a targeted review, request it before 8 PM Eastern on October 9th, 2023.

The adjustments earned with your 2022 MIPS submissions will appear in Medicare Part B payments for your 2024 services.

We expect CMS to release 2022 MIPS scores to the public in March 2024 and the 2022 QPP Experience report in June 2024.

So far, we know that a perfect composite score of 100 will earn an 8.25% positive payment adjustment. This is astounding. The highest positive MIPS payment adjustment we’ve previously seen was 2.34% for the 2021 performance year.

It breaks down, for 2022, to 2.23% on the core revenue-neutral MIPS program, with another 6.01% going to the top performers with an exceptional performance bonus.

These scores prompt two additional questions:

1. Why such a big jump?
2. What can we expect in future years?

The first thing to note is that 2/3 of this highest positive adjustment represents the exceptional performance bonus.

Medicare invested $500m yearly into the exceptional performance bonus for the first six years of MIPS. The 2022 performance year was the sixth year, and the exceptional performance bonus has sunset. This bonus will pay out in the 2024 payment year, then we don’t expect to see it again.

The second thing to note is that this top-tier exceptional performance bonus is much higher than we have ever seen. It’s the same $500m as previous years, now distributed between significantly fewer outstanding performers.

At this point, I think that this relates to two factors:

• The exceptional performance threshold was 85 for the 2021 performance year and went up to 89 for the 2022 performance year. A higher score was required to share in the bonus, and fewer providers and groups qualified, so more money goes to each high performer.
• The Cost performance category:
  • We last heard from the Cost performance category in the 2019 performance year. It was worth 15% of the total composite score.
  • CMS did not score Cost in 2020 or 2021 because of the pandemic.
  • For 2022, it was back at 30% of the total score.

Cost is the only category that CMS scores on a true percentile basis. The other three categories all have scores that cluster near the upper end of the range. Cost will have forced scores down on the average, driving far more providers and groups below the exceptional performance threshold than would be explained by just the increase in the exceptional performance threshold from 85 to 89.

So, what can we expect in future years of MIPS?

• The 2022 performance year was the last year of the exceptional performance bonus. This will significantly drop the highest possible positive adjustment for the 2023 years and beyond.
• Other dynamics will continue to push the maximum possible positive adjustment up:
  • In the 2024 Proposed Rule, CMS proposed setting the performance threshold at the average scores earned from 2017 to 2020.
    • Those years included bonuses for end-to-end electronic reporting and high-priority measures, which are now gone.
    • Cost was scored less heavily in those performance years, too.
• The Cost category is not going away:
  • Scores for Cost should average 15, half the maximum possible 30 points.
  • You should expect Cost to be the lowest-scoring category on the average.
• Finally, the pandemic is officially over. With its end, we can expect COVID-19 forgiveness to either suddenly or progressively end.
• With more groups having to participate, average scores coming down, and the performance threshold going up, there will be more practices with negative adjustments and a smaller set of practices earning positive adjustments to share in the more significant amount Medicare retains.

Question Two: QDC Codes for the APM Performance Pathway (APP)

Tom asks: “What do you think about QDC codes for our APM Performance Pathway (APP) Quality Reporting? We are a disseminated network. Our participating providers provide services across a wide geography using Electronic Health Records we don’t control.”

To start, let me explain QDC codes. “QDC” stands for Quality Data Code. They are, essentially, fake CPT codes Medicare invented when they first introduced quality reporting.

QDC codes are added to Medicare Claims to “report” to Medicare quality performance on that specific patient at that specific visit. They are codes meant to be part of the claim, not to result in payment, but only to be collected by Medicare to accumulate and calculate an annual performance score.

Every measure has at least two QDC codes:

• One code means performance is met.
• Another code means performance is not met.
• Other codes are used as needed for other concepts like:
  • Exclusions
  • Measure stratification
  • Additional clinical nuances

QDC codes were the foundation of claims reporting. Claims reporting has several weaknesses and has been slowly disappearing. Although all measures, even new measures, are still created and published with QDC codes in the specifications, even when those new measures are not eligible for claims reporting.

Typically, I prefer my practices to migrate to digital reporting and steer clear of QDC codes.

Your need, however, is the one place where QDC codes shine.

QDC codes are a great way to keep control of your quality reporting and deliver winning scores to Medicare when you don’t have control of the EHR, and you don’t have the clout to ensure that your needs for data extracts from the EHR will be honored and accurate.

Many good billing systems recognize when patient demographics, billed CPT, and ICD codes indicate a specific quality measure. Those systems prompt the billing provider to select the appropriate QDC code.

If you were doing quality reporting Medicare using the claims mechanism, you’d need those codes to go to Medicare.

But a good registry, like Mingle Health, can recover the QDC codes from your billing system and build a MIPS CQM submission around them. Unlike claims reporting, we can supplement the QDC-generated numbers with data from end-of-year manual chart abstracts to fill in holes you might have missed in the initial code selections made during service.

Over the long term, I still like digital reporting and think you should look ahead to a time when you maintain your patient database fed by automated data exchange each time you see a patient and document care in someone else’s EHR. It will give you the desired digital measurement capabilities and support the Promoting Interoperability data exchange measure requirements.

But now, you don’t have control of the local EHR. And it may be decades until you can rely on the data flow from each system. In the meantime, with QDC codes, you and your providers have control and can generate accurate and winning performance measures.

Question Three: Promoting Interoperability PDMP Measure

Maryann asks: “I’m trying to get a handle on the PDMP measure (Prescription Drug Monitoring Program) in the Promoting Interoperability MIPS performance category. I understand the measure now applies to Schedule III and IV drugs, not just Schedule II drugs. It seems a monumental task for my providers to comply with all Schedule II, III, and IV drugs. Where can I even find a list of Schedule III and IV drugs?”

Good news: This is easier than it seems!

The measure you’re referring to requires an attestation – It’s “Yes” or “No” attesting that:

• For at least one class II, III, or IV drug electronically prescribed
• For at least one patient during the performance period
• The provider (any one or more of your providers) conducted a query of the applicable PDMP system for prescription drug history

You don’t have to have an electronic integration with the PDMP system, and it does not have to be with every prescription.

Expanding to class III and IV drugs gives you more opportunities to comply. It does not represent a more significant requirement on your part.

As to a list of drugs by schedule, the gold standard is from the DEA and is found on their website here: DEA Diversion Control Division Controlled Substances Schedule >>

Question Four: MIPS Measures for Ophthalmology

Carrin asks: “What would you recommend for MIPS measures for the easiest, best, most efficient measures for an ophthalmologist?”

There’s no ophthalmology MIPS Value Pathway (MVP) yet, so you can’t go in that direction.

There is an ophthalmology specialty measure set. The typical advantage of specialty measure sets is that if you do them all, or all that apply to you, you get full credit, even if you don’t have six measures. But there are 15 measures in the ophthalmology measure set, including a couple that apply broadly but could be an awkward fit.

Five general measures theoretically apply to any provider, or nearly any provider, but could be an awkward fit for ophthalmology. Those measures are:

• #130: Documentation of Current Medications in the medical record
• #226: Tobacco Use: Screening and Intervention
• #238: Use of high-risk medications in older adults
• #374: Closing the Referral loop: Receipt of specialist report
• #487: Screening for Social Drivers of Health

These all generally fit in most specialties and can work in ophthalmology. But as a referring primary care physician, I don’t think I’d be looking at these specifically if I were judging the quality of the doctor to whom I was referring my patients.

There’s a single measure about macular degeneration:

• #14: Dilated Macular Exam

There are two diabetic eye measures:

• #19: Diabetic Retinopathy, communication with diabetic provider
• #117: Diabetic eye exam

There are four cataract measures:

• #191: Visual acuity 90 days post-op
• #303: Functional improvement 90 days post-op
• #304: Patient Satisfaction 90 days post-op (CAHPS surgical care survey)
• #389: Difference between planned and final refraction

There are two retinal detachment measures:

• #384: No return to OR within 90 days
• #385: Visual acuity improved after 90 days

There are also a couple of EMA Clusters – “EMA” stands for “Eligible Measure Applicability.” Medicare looks at these measures, and if you submit any one of them, they expect you to be able to submit all the others in the cluster.

So, if you submit one cataract measure in an EMA cluster, you should submit all four. If you submit any of the three internal eye care measures, they expect you to submit all three.

Those three internal eye care measures are the two retinal detachment and repair measures and the open-angle glaucoma measure.

There are also two Part B claims measures (included in the Ophthalmology Specialty Measure Set):

• #141: Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care
• #226: Tobacco Use: Screening and Cessation Intervention

So, if you’re a small practice – that is, 15 or fewer providers – you’re eligible to use Part B claims, and you could do those two measures for a complete submission.

The American Academy of Ophthalmology also operates a QCDR called the IRIS Registry, which has 26 measures. Medicare doesn’t require you to use a QCDR. If you can find a six measure set or a smaller set that you can justify through one of the above rules, that is fine.

If you are a solo practitioner or in a small practice, you can use the Part B claims method or an EMA Cluster.

I know in large groups, there’s often compartmentalization of the various eye problems, with one person doing cataracts, and other doing retinas, another caring for the diabetic eyes. So, together, you can choose the six best measures and put in a group submission.

It’s tough as a practitioner in a group practice to individually submit six measures. You’ll run into some rules that will limit your choices.

And, of course, we’re happy to help. As you’re going through this, you want to have an expert in your pocket to help do the eligibility screening to help you justify to Medicare when you don’t have enough patients to report any of these measures. If you get a first-pass denial of your submission, you may need to request a targeted review after the scores are released. Proving that you don’t have enough instances for some of the measures or that they don’t apply to your practice will be critical to a winning submission.

Send us your value-based care questions!

If you’d like to ask a question about the APP transition, MIPS, ACO quality reporting, or any other Alternative Payment Model, you can reach out to us in three ways:

You can leave your questions in a YouTube comment under any episode of Ask Dr. Mingle.

On LinkedIn, leave your questions in a comment on any of our posts.

And you can reach out directly by sending an email to hello@minglehealth.com.