In this episode of Ask Dr. Mingle, Dr. Dan Mingle answers Keith’s question about Eligible Measure Applicability (EMA) Clusters and how they apply to his specific situation as a solo ophthalmologist using paper charts. Later, Dr. Mingle further explains Keith’s options for his MIPS submission by dissecting other possible submission dynamics.

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Question One: EMA Clusters Explained

Keith asks: “I am a solo ophthalmologist who still uses paper charts.  I have received an exemption from MIPS for the last few years, but I expect that will not be available to me in 2024. My goal is to spend the least amount of time and effort on MIPS in order to minimize my penalty. The staff at Mingle suggested I submit an EMA cluster, which seems too good to be true. Could you provide a bit more explanation of EMA clusters?”

Yes, it does seem too good to be true.

First, I will answer your question about the EMA clusters specifically; then, I’ll put it into the context of your MIPS submission by dissecting your possible submission dynamics.

EMA Clusters Explained:

• EMA stands for “Eligible Measure Applicability.”
• Many specialists have difficulty finding six measures that are both measurable and applicable to them.
  • There is a lot of variation in the scope of practice in United States healthcare practices. That is, there is not a lot of standardization around specialty.
• Medicare does not want to be in the business of evaluating each provider’s or practice’s individual measure applicability and choices.
  • So they have created simple automated rules that provide good-enough-for-now assessment of measure applicability.

Eligible Measure Applicability (EMA) is one of the simple automated methods, and Specialty Measure Sets are the other.

The principle behind EMA clusters is that they are clinically related measures. Medicare assumes that if you submit one measure in a cluster, you should be able to submit all of the measures in the cluster.

If you submit six measures, Medicare will score them – any six measures.

Other than denominator specifications and measure completeness criteria, there are no prerequisite requirements to be eligible to submit any measure.

If you submit fewer than six measures, Medicare will look for EMA clusters and Specialty Measure Sets.

Suppose your submission is fewer than six measures but contains all of an EMA cluster or a Specialty Measure Set. In that case, your submission is judged complete, and CMS resets your perfect score to 10x the number of measures in the applicable set.

In your case, Keith, the Internal Eye Care EMA Cluster has three measures:

• Measure 141 for Open Angle Glaucoma and measures 384 and 385 regarding Retinal Detachment Surgery.
• This is an interesting and slightly unusual cluster where it’s relatively common that an ophthalmologist dealing with Open Angle Glaucoma does not also do retinal detachment surgery.
• To pass the EMA cluster, you have to submit all three measures. But Medicare does accept a shorthand to signal that you didn’t do any retinal detachment surgery in the year.
• If you have no Retinal Detachment Surgery, you will have no patients qualifying in the denominator. Therefore, you will report a ZERO denominator. Medicare will forgive the absence of a calculable score for the two retinal measures.
• Your six-measure requirement will go down to three using the Internal Eye Care EMA cluster.
• Your three-measure requirement will be one with ZERO denominators in the two retinal surgery measures.
  • Medicare won’t score those two measures – they will forgive their absence and give you a full score based on one measure.

Not all EMA clusters act this way.

Procedure-related measures most often do. Measurement of eligibility is generally clean and clear with procedure measures. If you’ve done the procedure, you’ve billed the procedure. Strictly following denominator specifications, ineligibility is apparent.

Other measures, not so much. In many measures, where eligibility is based on E&M and ICD codes, you can have denominator-eligible patients even if you don’t provide the care. ZERO denominators are generally not found.

To enjoy a similar dynamic to what I just described, you should submit your best data and then request a targeted review on what you expect to be poorly performing measures. I am not confident it will work, but you should do it anyway.

EMA Clusters Explained: Dissecting the Specific MIPS Submission Dynamics

Thanks, Keith, for the question about EMA clusters!

It may also be informative for our viewers to dissect all the possible dynamics of your MIPS submission.

Your needs fall within three of Medicare’s priority concerns, creating a solid path to minimize your penalty at least and possibly avoid it altogether.

What are Medicare’s concerns?

• First, small practices: Medicare is aware that MIPS could have an outsized negative impact on small practices compared to big ones with more resources. So, small practices have extra protections, such as automatic exceptions to the Promoting Interoperability performance category and favorable dynamics for scoring quality measures.
• Second, there is a shortage of specialty measures: Medicare knows many specialists have difficulty finding applicable measures. So, a couple of opportunities exist to permit full scoring of abbreviated measure sets.
• Third, differing scopes: Medicare is aware that there is wide variation in the scope of practice that can’t be fully explained by specialty designation. So, they have created simple automated rules that provide a good-enough-for-now assessment of measure applicability.

What does this mean, specifically, for you, Keith?

First, you get an automatic small practice exception to the Promoting Interoperability performance category.

For now.

For the foreseeable future, CMS excuses you from the requirement to use Electronic Medical Records.

Unless you choose to submit for the Promoting Interoperability performance category, it won’t exist for you.

Your peers in larger groups are scored 30% on Quality, 30% on Cost, 15% on Practice Improvement Activities, and 25% on Promoting Interoperability.

If you take the exception for PI, Quality is 40% of your score, with 30% on Cost and 30% on Improvement Activities.

Second: You may not be subject to any Cost measures.

You are not primary care, so you are not subject to the Total Per Capita Cost measure.

You probably have no significant inpatient volume, so you are not subject to Medicare Spending per Beneficiary.

There is an ophthalmology-focused cost measure for cataract removal. Medicare will measure that if you have at least 10 Cataract Extractions in the year.

If you don’t have Cost and you don’t have Promoting Interoperability, 50% of your MIPS score is based on Quality and 50% on practice Improvement Activities.

Third: On Quality, you have the EMA opportunity we described before and could use the Ophthalmology Specialty Measure Set.

There are only two measures in that set:

• Measure 141: Open Angle Glaucoma
• Measure 226: Tobacco use screening and care

This Specialty Measure Set only applies to Medicare Claims submissions.

It’s a hard one because every patient qualifies for tobacco use screening and care, and this is generally not a focus of ophthalmology practices.

Additionally, claims reporting is one of the most challenging reporting techniques to pull off. There are a lot of potential failure points.

Also, on Quality:

• There is still a small practice Quality bonus. CMS adds six points to the numerator when calculating the performance points in Quality.
  • It can’t pull you above a perfect score. So, it can’t make up for deficits elsewhere in your MIPS submission.
• There is still a three-point floor on any measure submitted, even if you report only one patient and/or a zero performance rate.
  • Three out of ten possible points is not great. If one applies, it’s better to use a small Specialty Measure Set or an EMA cluster.

Fourth: There is no escaping the need for practice Improvement Activities.

IA will represent 15% or 50% of your score under any dynamics except, like the COVID-19 exceptions, you qualify for a complete exception to MIPS reporting.

I suppose it’s possible to apply for and receive a specific exception to Improvement activities, but I’ve never heard of this happening.

Small practices, though, need half the activities that a larger practice requires. You only need two medium-weight or one high-weight activity.

I hope this has been helpful, Keith. I wish you easy and successful MIPS reporting!

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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:

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