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A Look at Data Completeness, and MIPS Success for Hospitalists | Ask Dr. Mingle

In this episode, Dr. Dan Mingle explains the CMS Data Completeness requirements and offers advice for navigating MIPS as a hospitalist.

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Questions and Answers in this Episode: CMS Data Completeness Requirements and MIPS for Hospitalists

Danielle asks: “Can you explain data completeness? Is it 70% of the denominator? CMS says that if we report with eCQMs, we need 100% of our data.”
  • An explanation of the CMS data completeness criteria could be helpful here: to meet the requirements, you must have quality measure responses for 70% of the denominator data, and that denominator has to be accurate.
    • An accurate denominator represents 100% of the patients who are eligible for the measure in question. Once you’ve determined the denominator, you must represent at least 70% of the data in those instances.
    • Once you’ve determined your denominator and know it’s accurate, you’ll be able to assess your numerator data and ensure you are reporting numerator data for at least 70% of your eligible patients.
  • If all your eligible patients – your denominator for a measure in question – are in a single EHR, CMS automatically assumes that you have 100% of your data.
  • Of course, this may not always be the case. Many organizations work with multiple EHRs across several member practices. You’ll need a combined data set if you work with different EHRs or bring data from an outside source (like a tumor registry).
    • Missing data will cause your submission to be incomplete and could lead to penalties and poor performance.
  • Mingle Health can help in this situation: we’re experts at collecting all of your data using your claims. We can combine this data into a single data set before running assessments of your performance. With our help, you’ll have all of your data in one place, and you’ll be able to see your performance throughout the year and make adjustments that impact reimbursements.
Rick asks: “Our providers don’t admit patients – we make rounds at hospitals – so we don’t have answers to quality items for those patients. How can we meet the 75-point minimum in MIPS?”
  • In MIPS, CMS expects you to do your best to find six measures to submit. But, there are plenty of providers who have no applicable measures or have less than six applicable measures. These instances require special attention and an adjustment of strategy for your MIPS submission.
  • First, you may qualify for an exception based on your specialty. You can start looking for exceptions that fit your situation right away.
  • You can use a specialty measure set to make your submission. CMS offers approximately 30 different specialty measure sets. If you go this route, you’ll have to submit every measure in the specialty measure set to satisfy CMS’s requirements.
    • There’s still a chance that you won’t be able to generate the data required for a specialty measure set. In this case, submitting a zero numerator over a zero denominator is valid if a high-quality data analysis shows that you have no eligible instances for a specialty measure set.
  • Another option is to use a Qualified Clinical Data Registry to fill out six measures that apply to your specialty. You aren’t required to work with a QCDR vendor, but it may be a great option in your circumstance.
  • You are also allowed to submit data that you didn’t generate. CMS encourages providers to work as teams when applicable. If you’re a specialty provider and take referrals, you can use data generated by the providers whose referrals you’re taking.
    • An example of this could be flu shots. You may not perform flu shots for your patients, but you could report the flu shot measure from a shared record with other providers.
  • Facility-based reporting is also an option. As a hospitalist, most of your charges are in a hospital setting. If the hospital you’re working in has a facility-based quality submission, you can access that submission.
    • You can find out if you’re eligible for this method on the Participation Status Page of the QPP website. On this page, you can enter your NPI and check to see if your current status is facility based.
  • Consider an Eligible Measure Applicability set (commonly referred to as an EMA cluster). An EMA cluster is similar to the specialty measure set rules outlined above.
  • Finally, consider applying for a Hardship Exception or Targeted Review after submission. You can apply for a Hardship Exception before the deadline, and CMS will review your situation.
    • After your submission, you can apply for a Targeted Review – but don’t rely on this alone to help your situation. CMS could negatively respond to your review, and you may have to take additional action.

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

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