Complying with MACRA

APRIL 2020 | CMS to Apply MIPS Extreme and Uncontrollable Circumstances Policy In Response to COVID-19, Reopens Application

CMS is offering multiple flexibilities to provide relief to clinicians responding to the 2019 Novel Coronavirus (COVID-19) pandemic. In addition to extending the 2019 Merit-based Incentive Payment System (MIPS) data submission deadline to April 30, 2020 at 8 PM ET, the MIPS automatic extreme and uncontrollable circumstances policy will apply to MIPS eligible clinicians who do not submit their MIPS data by the April 30 deadline.
If you are a MIPS eligible clinician and do not submit any MIPS data by April 30, 2020, you won’t need to take any additional action to qualify for the automatic extreme and uncontrollable circumstances policy. You will be automatically identified and will receive a neutral payment adjustment for the 2021 MIPS payment year. Please note, CMS has updated the QPP Participation Status Tool so eligible clinicians can see if the policy has been automatically applied.

---

IAC Accreditation Satisfies MIPS Improvement Activity for 2020 Payment Year

FEBRUARY 2020 | Physicians may utilize IAC accreditation as a Centers for Medicare & Medicaid Services (CMS) MIPS Improvement Activity to satisfy a component of the MIPS Improvement Activity score under an existing category IA_PSPA_19, Patient Safety And Practice Assessment for Quality Payment Program Year 4 (2020). Physicians will need to document a component of the accreditation requirement for 90 days (such as patient dose tracking in CT) to satisfy the improvement activity and report via attestation to CMS.

The IAC Quality Improvement (QI) Tool is an independent option that may also be utilized to satisfy MIPS Improvement Activity and MOC. More information about MIPS improvement activities can be found at qpp.cms.gov/mips/improvement-activities.

Upcoming MIPS Important Dates and Deadlines

The Centers for Medicare & Medicaid Services (CMS) would like to remind clinicians of important upcoming Merit-based Incentive Payment (MIPS) dates and deadlines:

  • March 31, 2020 – 2019 MIPS performance period data submission window closes and First Snapshot for Qualifying Participant (QP) Determinations and Merit-based Incentive Payment Systems (MIPS) Alternative Payment Model (APM) Participation
  • April 1, 2020 - Registration Begins for CMS Web Interface and Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Survey
  • Spring/Summer 2020 - Quality Payment Program Exception Applications Window Opens
  • June 30, 2020 - Registration Ends for CMS Web Interface and CAHPS for MIPS Survey
  • August 31, 2020 - Third Snapshot for QP Determinations and MIPS APM Participation
  • October 3, 2020 - Last Day to Start a 90-day Performance Period for Promoting Interoperability and Improvement Activities
  • December 2020 - PY 2020 Eligibility Finalized
  • December 31, 2020 - PY 2020 Ends

2020 Resources

2020 Payment Year

I. Quality Requirements (45% of Final Score)
You must collect measure data for the 12-month performance period (Jan 1 - Dec 31, 2020). The amount of data that you must submit (“data completeness”) depends on the collection (measure) type. Read more»
II. Promoting Interoperability Measures Requirements (25% of Final Score)
You must submit collected data for measures from each of the 4 objectives (unless an exclusion is claimed) for the same 90 continuous days (or more) during 2020. Read more»
III. Improvement Activities Requirements (15% of Final Score)
To earn full credit in this performance category, you must generally submit one of the following combinations of activities:
- 2 high-weighted activities
- 1 high-weighted activity; and
- 2 medium-weighted activities; or
- 4 medium-weighted activities

Improvement activities have a continuous 90-day performance period (during CY 2020) unless otherwise stated in the activity description.
The IAC QI Self-Assessment Tool (Implementation of formal quality improvement methods, practice changes, or other practice improvement processes, Activity ID IA_PSPA_19) or the IAC QI MOC Activity(Participation in MOC Part IV, Activity ID IA_PSPA_2) satisfy the requirements of the Patient Safety and Practice Assessment Subcategory. Read more»
IV. Cost Measures Requirements (15% of Final Score)
For Performance Year 2020, we use cost measures that assess the total cost of care during the year, or during a hospital stay, and/or during 18 episodes of care for Medicare patients. There are 20 cost measures available for Performance Year 2020. MIPS Alternative Payment Model (APM) participants are not scored on cost under the APM scoring standard. Read more»

2019 Payment Year

I. Quality Requirements (45% of Final Score)
Participants collect measure data for the 12-month performance period (January 1 - December 31, 2019). The amount of data that must be submitted depends on the collection (measure) type.
II. Promoting Interoperability (PI) Requirements (25% of Final Score)
For Performance Year 2019, 2015 Edition CEHRT is required for participation in this performance category. Participants must submit collected data for certain measures from each of the 4 objectives measures (unless an exclusion is claimed) for 90 continuous days or more during 2019.
III. Improvement Activities Requirements (15% of Final Score)
To earn full credit in this performance category, participants must submit one of the following combinations of activities (each activity must be performed for 90 continuous days or more during 2019):
- 2 high-weighted activities
- 1 high-weighted activity and 2 medium-weighted activities
- 4 medium-weighted activities
The IAC QI Self-Assessment Tool (Implementation of formal quality improvement methods, practice changes, or other practice improvement processes, Activity ID IA_PSPA_19) or the IAC QI MOC Activity(Participation in MOC Part IV, Activity ID IA_PSPA_2) satisfy the requirements of the Patient Safety and Practice Assessment Subcategory.
IV. Cost Measures Requirements (15% of Final Score)
For 2019, MIPS uses cost measures that assess the beneficiary's total cost of care during the year, or during a hospital stay, and/or during 8 episodes of care. MIPS Alternative Payment Model (APM) participants are assessed on cost through the APM. Therefore, they are not scored on cost under the MIPS APM scoring standard.

For information on MIPS data submission, visit qpp.cms.gov/mips/individual-or-group-participation.

The IAC is committed to assisting participating facilities to ensure clinicians within accredited facilities earn credit under MIPS for their quality efforts. For further assistance from the IAC related to satisfying components of quality initiatives through IAC accreditation, contac info@intersocietal.org.

IAC Resources

  • IAC QI Self-Assessment Tool - The IAC QI Self-Assessment Tool is a free feature, created to help your facility document and analyze continuous process improvement and meet the quality measures required by the IAC Standards.
  • IAC QI MOC Activity - A Quality Improvement (QI) self-assessment activity to provide interpreting physicians with an online tool to assess quality metrics as required by the IAC Standards and Guidelines.

MIPS Overview

This information was referenced directly from the CMS Quality Payment Program website (qpp.cms.gov)

CMS is required by law to implement a quality payment incentive program, referred to as the Quality Payment Program, which rewards value and outcomes in one of two ways: Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). Under MIPS, clinicians are included if they are an eligible clinician type and meet the low volume threshold, which is based on allowed charges for covered professional services under the Medicare Physician Fee Schedule (PFS) and the number of Medicare Part B patients who are furnished covered professional services under the Medicare Physician Fee Schedule. Performance is measured through the data clinicians report in four areas - Quality, Improvement Activities, Promoting Interoperability (formerly Advancing Care Information), and Cost. CMS designed MIPS to update and consolidate previous programs, including: Medicare Electronic Health Records (EHR) Incentive Program for Eligible Clinicians, Physician Quality Reporting System (PQRS), and the Value-Based Payment Modifier (VBM).

There are four performance categories that make up the final score. The final score determines what your payment adjustment will be. These categories are: Quality, Promoting Interoperability, Improvement Activities and Cost.

The MIPS Performance Year begins on January 1 and ends on December 31 each year. Program participants must report data collected during one calendar year by March 31 of the following calendar year. 

For future deadlines and submission dates, refer to qpp.cms.gov/about/deadlines.