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APM Performance Pathway (APP) Reporting Challenges with Laura Dietzel | Ask Dr. Mingle

In this week’s episode, Dr. Dan Mingle interviews Laura Dietzel, a Senior Clinical Informatics Analyst at Mingle Health, about her work helping ACOs transition to the APM Performance Pathway (APP) for quality reporting to CMS.

Click play on the video below to hear Dr. Mingle and Laura discuss:

  • The timeline for ACOs still transitioning to the APM Performance Pathway
  • Data sources for APP reporting featuring details about required data, how to find or generate necessary files, and how to pass that data to your reporting vendor
  • Common APP reporting challenges that Laura has seen while working with ACOs
  • And why data readiness and a proactive approach to understanding your organization’s data is a key element to success in the APP transition

Question One: Laura Dietzel’s Work at Mingle Health

Dr. Mingle asks: “Can you tell us a little bit about what you do on the clinical informatics team here at Mingle Health?”

Laura: One of my primary tasks is helping our ACO clients with the acquisition, evaluation, and processing of the data they will use to report the APM Performance Pathway (APP) quality measures.

Our team leverages many years of working with many different systems, both on the billing side and on the EHR side of the workflows, to help clients both leverage the data that they currently have to report CQMs, as well as develop additional data sources, improving their data governance and their data readiness for reporting quality measures.

Question Two: APM Performance Pathway (APP) Transition Timeline

Dr. Mingle asks: “I’m sure most are aware of this, but what is the timeline for the APM Performance Pathway transition?”

Laura: 2024 is the final year that ACOs can report quality measures using the Web Interface method.

In response to that deadline, many ACOs are engaging Mingle Health to help them start reporting either the traditional MIPS CQMs or the Medicare CQMs, or, in some cases, we’re being asked to help ACOs evaluate their readiness to report one or the other.

We see some ACOs jumping right into reporting, and some are evaluating their ability to report while still using the Web Interface for the final year that it is available.

Our clients are using a variety of approaches in this final year before the APP is a requirement. They’re investigating readiness and either starting to report now or evaluating and improving readiness to report APP quality measures next year.

Question Three: Data Requirements for an APP Submission

Dr. Mingle asks: “What data does an ACO need to successfully construct a good APP submission?”

Laura: There are two data sources that we look for.

First, we look for the claims data. That needs to come from a billing system in whatever form is available; we can take flat or 837 files. Those are the two things we look for from the billing systems in all of an ACO’s member practices.

Then, we look for clinical data that comes from the workflow of an EHR.

We look at all the various EHR systems in the ACO and look for flat files, QRDA files, or any type of extract that can help us access that numerator (clinical) data. When we can access data this way, clinics can avoid manual chart abstraction and its associated costs.

Question Four: Billing Data for APP Reporting

Dr. Mingle asks: “Laura, you mentioned two kinds of data, claims or billing data on one hand – which I think you’re telling us is a source of denominator data – then clinical data. Let’s break them down for a moment. Tell us more about the claims data. What is it, and what do we look for in it? And where do our clients usually find that data?”

Laura: If you look at the specifications for each of the three APP quality measures, the denominator for the measure is the population being evaluated, defined by a set of CPT and ICD codes.

Those codes come from the claims data, either a flat file, 837, or whatever file our clients can produce, either from a vendor product or from a billing service. We can fluctuate wherever the data can be found and work with those sources.

When we ingest those claim files, we create a denominator for each quality measure. The next step is to look for the numerator data from the clinical systems.

Question Five: 837 Files Explained

Dr. Mingle asks: “Now, what is an 837 file? Is that something that our clients must generate out of their system? Can you tell us where that comes from?”

Laura: An 837 file is a national standard created for collecting and submitting billing data from the practice to the payer.

At Mingle Health, we can leverage those files to create the denominator for the three CQMs we report to CMS.

Whether an 837 or a flat file, these files are available from your billing system or vendor.

So they’re not a unique product that is needed that you need to create to submit quality data for the CMS programs. They’re already available.

However you’re submitting that data to your payer, it is the same product we can use to create the denominators for the quality measures. 837s or flat files – either option will work equally as well. But they should already be available in your system.

Question Six: How to Access & Export Billing Files

Dr. Mingle: “Can you give any tips, Laura, for how our clients end up finding those billing files? Do they have to go on a hunt through their systems? Or what are the resources they can use to get access to these?”

Laura: Typically, the practice management system includes products that export billing files—either flat files or 837s.

So those same products that are in the billing system to send the data to the payer are the same products that we’d use to grab that same data and use it for the quality reporting.

It should be readily available either from your practice management system or the vendor you’re using. Your system or vendor creates those billing files and sends them on your behalf to your payer.

We ask clients to take those same files and copy them to us, and we use those files to create the denominator for the three quality measures.

Question Seven: Clinical Data for APP Reporting

Dr. Mingle asks: “Let’s move on to the clinical data. What are the typical sources of clinical data that our clients discover and send to us?”

Laura: There are three ways that clients typically report numerator (clinical) data.

The ideal way is to leverage whatever structured data comes out of the workflow into a structured field in an EHR. This way, we can just pull that data from the EHR and use that to calculate a numerator.

The other way clients report measures is through claims codes or Quality Data Codes (QDCs). These are non-billable codes that can be included in the claim. If clients have been using those or want to use them annually, maybe for the annual wellness visit, they can collect a couple of codes from that process that can also help report numerator data.

Finally, the most manually intensive approach and the most expensive approach to reporting the numerators would be through manual chart abstraction. This means reviewing the chart and putting the responses into a product that we provide. Then, we can use the data that’s been manually collected to calculate the numerator.

Question Eight: APP Reporting Challenges for ACOs

Dr. Mingle asks: “Now when we engage with a new client to create a quality submission for them, and they start looking for their data, what are the common surprises that they’re running into? What are the common APP reporting challenges?”

Laura: I think several challenges are surprising to our ACO clients.

Contract restrictions are probably the first or the most predominant surprise. Either the contract with their EHR vendor or, sometimes, restrictions within the ACO membership.

Within ACOs, there are often challenges around who can see whose data.

Or the EHR vendors may have restricted the kinds of data our clients can extract from their systems.

In these cases, we need to go back to the table, get partners to talk to each other, and come up with new agreements by way of exchanging data. Sometimes, clients will need to renegotiate vendor contracts where they get access to more data types, more data extraction, or more extraction tools.

That’s one thing that we’re seeing as a surprise to vendors or clients who are collecting numerator data.

Another challenge has been the volume of the data.

These measures, especially measure 134, the depression measure, have a broad denominator. Most of the encounters in an ambulatory care environment will qualify for that measure.

One of the other surprises clients are finding is the sheer volume that they are finding reported for these three measures.

If you have a data gap and are reporting 3000 patients for a quality measure versus 300 patients, that data gap can translate to much more manual effort to report the quality measure.

These higher volumes than might have been expected lead to much higher than anticipated chart abstraction costs to collect all the data needed to meet the reporting rate or the performance goal.

Question Nine: How ACO Member Practices Transfer Data to Mingle Health

Dr. Mingle asks: “Now, just a point of clarification for me, Laura. You’re describing a lot of different ways of getting this data and the surprises around them. In these complex organizations that are ACOs, do they have to come up with the same way for each of their practices of getting data to us?”

Laura: They do not.

That’s the nice thing about being able to work with a registry. A registry has the flexibility to combine the data in whatever form it’s being found in all of these member practices.

For example, if some member practices have very mature workflows on their EHR product, they’re collecting a lot of excellent, robust data that they can export, for example, as a QRDA I. That’s a great way for us to leverage all of the data they’ve collected and help them avoid any chart reviews when reporting the data.

Other members within that same ACO could still be on paper charts, or they might be struggling to implement a switch from one EHR to another EHR during the year.

Registries can come in and pull the right data at the right time to fully and accurately define the denominator and the numerator for these clients.

We can use chart review, and we can help clients start collecting quality codes in their workflow, whatever they are able to do by way of assisting them in reaching the reporting rate requirement, the data completeness requirement, and their performance goal. We can work with those goals on the ground.

Question Ten: Data Readiness for APP Reporting

Dr. Mingle asks: “In your experience working with these larger organizations, what would you describe as the key indicators of success? What makes a difference between those organizations you see struggling with this and those who pull it all together for a successful submission?”

Laura: Yeah, great question, Dan.

This is one point that I have a lot of passion for with regard to helping our ACO clients be successful: data readiness.

To me, that means taking some time and the resources to dive into what these three measures are asking for, the data that they’re asking about.

Certainly, a lot of our clients are ready to dive in and start pulling the data and reporting the measures. But a few are actually even asking if they’re able to collect this data on a timely basis across the ACO membership.

And so that data readiness piece and that data discovery piece before diving in, will help ACO clients best prepare for success.

So, what do I mean by data readiness?

First, it means going to each of your member practices and getting hands on the data we need to create the denominator.

It’s important to start getting those pieces in hand.

Oftentimes, we find that ACO members have been asked questions like: “Can you produce these files? Can you send us this kind of data?”

They feel confident they can, but when it comes down to the rubber hitting the road, again, we’ve run into contract constraints:

  • You don’t have access to pull the data from your system.
  • Or you need to pay your vendor to pull this data from your system.

For the delivery body or the person who’s going to do the reporting, this sometimes ends up being a surprise.

It’s vital to start collecting data samples from all of those data sources and making sure you have free access to your claims data. And across the ACO and different EHRs for your numerator data, whatever you can extract from these systems is key.

And the other piece is just understanding the volumes.

Do you understand how many patients are going to be pulled into these denominators?

Have you reviewed where your data gaps are with regard to reporting?

Understanding the data needed to report these quality measures, its availability, and any gaps in their data will be crucial to success.

Question Eleven: Tools for APP Reporting

Dr. Mingle asks: “Laura, I take it that you are prepared, or Mingle as a company is prepared, to help our clients however they wish? If they can bring the data together and then bring it to us, that’s great. Or if they want us to handle the data directly from the members and then just give them the aggregate data back, I take it we do both?”

Laura: We’ve done a lot of work in the last year to develop a variety of project tools that are specific to this APP program.

File management tools are one area where we can really help.

We can assist in organizing, managing, and curating your data before it is passed to Mingle to help your membership better understand the nature of the data that they’re sending and where there might be gaps in that data.

We are always developing a lot of tools to help folks understand information about the data they can send, the files they’re collecting, and the timeliness of the whole APP reporting process.

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

Want to learn more about the APM Performance Pathway (APP)?

For many ACOs, the transition to all-patient, all-payer quality reporting is a significant challenge and often feels like an unnecessary burden imposed by CMS. We've created our latest PDF guide to help ACOs orient themselves to the challenge of all-patient, all-payer reporting while finding opportunities to thrive in the future.

Access the Guide
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