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Q&A on MIPS with Dr. Dan Mingle – Part 2

To help clarify some challenges to understanding the new MIPS and Quality Payment Programs, here is another edition of Q & A on MIPS with Dr. Dan Mingle, featuring popular questions I’ve been asked from individuals across the country.

Don’t miss our other MIPS resources:

If you still have questions after reading my post, I urge you to submit them in the comments section below. I’ll be eagerly standing by to answer them.

Advancing Care Information

Q.  For the ACI/new MU category: you mentioned that to receive a 10% one-time bonus, we can perform an improvement activity that involves use of CEHRT, like sending a summary of care or patient-specific education. But how much leeway do we have within the ACI/MU categories? For example, we eFax specialist reports back to the PCP using our EMR system (closing the referral loop for Improvement Activities). But this is not done through VDT, or the patient portal, etc. Would it still qualify for the 10% bonus points?

A.  A CMS ACI fact sheet lists specific improvement activities that are eligible for the ACI bonus. The first one on the following reproduction of that list is the one that references “closing the referral loop.”

  • Implementation or use of specialist reports back to referring clinician or group to close referral loop
  • Provide 24/7 access to eligible clinicians or groups who have real-time access to patient’s medical record
  • Anticoagulant management improvements
  • Glycemic management services
  • Chronic care and preventative care management for empaneled patients
  • Implementation of methodologies for improvements in longitudinal care management for high-risk patients
  • Implementation of episodic care management practice improvements
  • Implementation of medication management practice improvements
  • Implementation of documentation improvements for practice/process improvements
  • Implementation of practices/processes for developing regular individual care plans
  • Practice improvements for bilateral exchange of patient information
  • Use of certified EHR to capture patient reported outcomes
  • Engagement of patients through implementation of improvements in patient portal
  • Engagement of patients, family and caregivers in developing a plan of care
  • Use of decision support and standardized treatment protocols
  • Leveraging a QCDR to standardize processes for screening
  • Implementation of integrated PCBH model
  • Electronic Health Record Enhancements for BH data capture

To get the bonus points, you will need to use your CEHRT. The rules don’t specify exactly how the specialist report needs to be sent.  Since you are using your CEHRT to eFax the report, and the record is maintained in CEHRT of the report being sent, I expect eFax through CEHRT will satisfy the requirement.

Q.  Since CPOE is no longer a part of the ACI compliance piece of MIPS/MACRA for 2017, does this mean that the rule surrounding who can enter information into the EMR goes away? We had some staff getting credentialed as RMAs, CMAs in years past because of these requirements. Is there a requirement that MAs still be “certified” with licensure or credentials in order to enter orders and the like into the medical record?

A.  CPOE as an EHR utilization measure is gone in the conversion from Meaningful Use in the EHR Incentive Program to Advancing Care Information in the MIPS program.

But neither Medicare nor ONC has offered guidance and has never, to my knowledge, established any written rules, regarding who can or cannot enter information into the EHR.

CMS guidance is available in the following two links:

CMS Guidance: Page 1

CMS Guidance: Page 2

Note that Medicare’s guidance, linked above, are only suggestions. They do not constitute rules, requirements, or even prerequisites of the CPOE measure. Removal of the CPOE measure has no impact on the practice-specific decision about who should or should not enter clinical orders or any other data into the EHR.

These issues are governed at two levels:

  1. At the State level, specific rules and regulations managed by the applicable Boards of Licensure or Registration in Medicine, Osteopathy, Nursing, and others often specify who may or may not perform certain professional activities
  2. At the local or Practice level, it is a matter of local policy set by each healthcare provider, practice, or organization, exactly what staff they permit to do what and under what circumstances.  The circumstances include the baseline training and credentials of the staff supplemented by additional training, guidance, and level of supervision provided on the job.

In States whose rules I am familiar with, staff can be trained and supported by the licensed clinician to whatever extent and to whatever functional scope the licensed clinician is comfortable within that clinician’s scope of licensure.

The best guidance through the local rules and the formal and informal standards of practice is probably from the State Medical Association.

Q.  How are hospital-based practices like ER groups and hospitalists affected by the ACI Category?

A.  The ER group is most likely to meet the MIPS definition of hospital-based and are exempt from the Advancing Care Information category. “Exempt” in this case means that the hospital-based clinician can elect to report in the ACI category or not.  If the hospital-based clinician elects not to report ACI, the 25 points that would be applied to this category are reallocated to Quality so that the Quality category is worth 85 points, instead of 60. A hospital-based clinician is one “…who furnishes 75 percent or more of his or her covered professional services in sites of service identified by the Place of Service (POS) codes, inpatient hospital (POS 21), on-campus outpatient hospital (POS 22), or emergency room (POS 23) setting….”

Read our blog post, Advancing Care Information: What You Need to Know for 2017, to learn more about how you can prepare for success in the ACI performance category.

Improvement Activities

Q.  You mentioned that in the transition year of MIPS we may have to prove that some activities were done for at least 60% of patients. How can we prove this if some of the data isn’t captured in our EHR? Would our word be sufficient since it is a YES/NO attestation for each? Also, if submitting as a group, will we need all physicians to qualify for four activities each?

A.  Your word is sufficient for reporting improvement activities, but you should be ready to produce your proof if audited. On the QPP website, CMS has published guidance (“MIPS Data Validation Criteria”) for what documentation should be maintained for each of the improvement activities in case of an audit.

For instance, if you are using a warfarin control program as your improvement activity, and you need to demonstrate you have met the 60% required, you would generate a list showing the complete list of patients on warfarin and generate a list of those who are participating in the control program.

When reporting Improvement Activities as a group, one provider performing one activity is enough to give credit to the whole group for the activity. You will need to identify 2 high value activities, 4 medium value activities or 1 high value and 2 medium value activities. Each activity need only involve one provider.

Dr. Mingle gives a concise overview of the Improvement Activities performance category in his webinar, MIPS: Succeeding with the Clinical Practice Improvement Activities (CPIA) and Cost Performance Categorieswatch the recording and download the slides from the webinar now!


Q.  Can you please clarify if there is a required minimum patient denominator for any measure?
I have 2 measures where we have less than 20 in the denominator but we are at 100% score for the measures. I thought you had mentioned that there must be at least 20 patients in the denominator for CMS to allow reporting on the measure. Would we be able to report these measures?

A.  You can report measures with fewer than 20 patients in the denominator. You will get credit for such measures against the required measure count. Any measures with fewer than 20 patients will only receive 3 points, regardless of how well you perform on the measure. You can only get full credit for great performance if the measure has 20 or more patients in the denominator.

Q.  For the minimum requirements, if an Eligible Clinician chose to report a single quality measure, does it have to be for a minimum of 90 days?

A.  Quality reporting does not have to be for 90 days. To avoid the penalty, reporting on one patient for one visit is adequate but we (and CMS) encourage you to report more data than the minimum requirement. If you meet the full “data completeness criteria”: 90 days, 50% of patients from all payers, each measure meeting the case minimum of 20 patients, you have the potential to be eligible for up to 10 points per measure plus bonus points, where applicable.

Q.  Can a high-priority measure replace an outcome measure even when not reporting a specialty measure set?

A.  Yes. A priority measure will replace an outcome measure whether using a specialty measure set or not.  To substitute a high-priority measure, you have to be prepared to show that no outcome measures are applicable to your practice.

Q.  Where can “official” Quality measure specifications be found?

A.  “Official” Quality measure specifications can be downloaded from the Quality Payment Program website in the Education and Tools section. You will also have specifications available after registering with MIPS Solutions. You can also download our reference guide for a comprehensive list of the 2017 MIPS Quality Performance Category measures.

The Quality performance category accounts for 60% of your MIPS Final Score for 2017, make sure you’re prepared by watching Dr. Mingle’s recorded webinar, MIPS: Succeeding on Quality (formerly known as PQRS).

Hospital Based Questions

Q.  Hospital based providers are now included as Eligible Clinicians in MIPS. How will the Quality category be reported if there are multiple providers providing care for one patient?

A.  The requirements and logistics for reporting each measure are set in published measure-specific specifications.  Some measures may be reported by only the admitting provider.  Some measures are reported by only the discharging provider.  Some measures are reported by every provider who generated any bill for any visit to the patient during the hospitalization.

Q.  As a hospital-associated clinic, do we view ourselves as a solo-practitioner or part of the hospital system when reporting for MIPS?

A.  This should be determined with how you are billing your Medicare claims. If you bill under the hospital TIN, you would be considered part of the hospital system in terms of MIPS reporting. If you bill your Medicare claims under your own unique TIN, then you would be considered a solo-practitioner. In any circumstance where a number of individual clinicians bill Medicare under the same TIN, that TIN is considered a group practice.  The clinicians in any group practice can decide to report as a group, submitting one report that applies equally to everyone.  Or they can decide to each report individually as if they are each solo practitioners.  The decision applies to everyone.  All practice providers are part of one group submission, or each practitioner submits individually.  It cannot be mixed.

General MIPS Reporting Questions

Q.  Are all the four categories within MIPS reported together in the same “portal”?

A.  There is no reporting burden for the Cost Performance Category.  Cost, when it is reintroduced after the 2017 performance year, will be calculated by Medicare from Claims submitted.  Reports must be submitted for the Quality, Advancing Care Information, and Practice Improvement Activities categories.  Those three performance categories can be reported through a CMS-qualified Registry, QCDR or EHR if the vendors are configured to accept and report the data.

Q.  What does a practice do if they do not have an EHR?

A.  Practices which do not have an EHR would not be able to receive a score in the ACI category. Such practices begin each submission with a 25-point handicap representing the 25 composite final performance score points that cannot be earned for “Advancing Care Information” without an EHR. If you are a hospital- based practice or have non face-to-face providers, you can exempt from ACI and avoid the 25 point handicap by assigning those 25 points to the quality category. There are other ACI exemptions that could do the same thing for you (you might be exempt and those points would be reallocated to the Quality category). Put your effort into scoring well in the Quality and Improvement Activities categories. If you score well in those categories, you can still earn an incentive. Even if you cannot exempt from ACI, there are still 75 composite performance score points that can be earned for Quality and Practice Improvement Activities. 75 points can put your practice in the incentive range without an EHR.

Did you find this post helpful? Just in case you missed it, here is a link to Q&A on MIPS with Dr. Dan Mingle, Part 1.

Looking for more answers? Post your questions in the comments below. You can also find additional information on our MIPS FAQ page, in our free E-Book, or by contacting our team of friendly consultants to make sure you are prepared for the new Quality Payment Program starting in 2017!


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