Quality Payment Program: MIPS Reporting Options

As with prior years when the Physician Quality Reporting System (PQRS) was in place, there were several options to choose from to report quality measures to CMS.  Those options are still in place for reporting under the Quality Payment Program (QPP).  Each reporting option for the Quality category of the Merit-Based Incentive Payment System (MIPS) is detailed below.  Also described below are details behind participating in MIPS as an individual or a group.

Claims-Based Reporting

  • ADVOCATE is prepared to report claims-based measures for our clients throughout Performance Year (PY) 2017
  • Claims-based reporting is the only option if participating in MIPS as an individual eligible clinician (EC)
  • Limited to Medicare Part B and Railroad Medicare patients
  • Pros:
    • Readily accessible as it is part of the routine billing process
    • No need to contact a registry or EHR vendor to submit data
    • Simple to select measures and begin reporting
    • No associated fees
  • Cons:
    • Claims-based reporting is a “one shot deal” – CMS does not allow submission of a corrected claim for the purposes of PQRS (now MIPS Quality measures)

Electronic Health Record

  • Electronic reporting of MIPS Quality measures using an EHR
    • Submit MIPS Quality measure data directly from the CEHRT
    • Submit MIPS Quality measure data extracted from the CEHRT to a qualified EHR data submission vendor (DSV) who submits on behalf of the MIPS EC
  • Data submission period: January 2018-February 2018 for PY 2017
  • Bonus points available for reporting through EHR
  • Required to report across all payers

CMS Web Interface

  • The Web Interface is a secure internet-based application available in the CMS PQRS Portal to pre-registered users where CMS pre-populates a sample of the group’s patients. The group then has to provide PQRS data for those pre-selected patients for which CMS will then calculate reporting and performance rates.
  • Bonus points available for reporting through CMS Web Interface
  • Only a reporting option for groups with 25 or more ECs
  • Data submission period: January 2018-February 2018 for PY 2017
  • Limited to Medicare Part B and Railroad Medicare patients

Qualified Registry

  • A qualified registry is an entity that collects clinical data from an individual EC or MIPS group practice and submits it to CMS on behalf of the participants
  • Data submission period: January 1, 2018-March 31, 2018 for PY 2017
  • Bonus points available for reporting through qualified registry
  • Associated fees variable by registry company
  • Able to submit data to CMS on the highest scoring measures
  • Larger set of quality measures to choose from
  • Required to report across all payers

Qualified Clinical Data Registry (QCDR)

  • A QCDR is a CMS-approved entity that collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care provided to patients; and is available to individual ECs and group practices
  • The American College of Radiology’s National Radiology Data Registry (NRDR) has been approved as a QCDR for the purposes of CMS reporting
  • The ACR has not yet published the 2017 performance year fees (highest associated cost out of all reporting options) or key dates
  • The NRDR warehouse encompasses a number of other registries, including, as examples, the General Radiology Improvement Database and the National Mammography Database, as well as the CT Colonography Registry, Dose Index Registry, Lung Cancer Registry, and Society of Interventional Radiology Registry.
  • Bonus points available for reporting through QCDR
  • Data submission period: January 1, 2018-March 31, 2018 for PY 2017
  • Able to submit data to CMS on the highest scoring measures
  • Several Clinical Practice Improvement Activities (CPIA) emphasize the use of a QCDR
  • Larger set of quality measures to choose from as well as streamlined reporting across all MIPS categories
  • Required to report across all payers

Individual Reporting

  • Claims-based reporting is the only option if participating in MIPS as an individual EC
  • Payment adjustments will be assessed at the NPI/TIN level
  • If a provider is participating in the Quality category of MIPS as an individual, then they have to participate as such across all applicable MIPS categories.  The submission method for the CPIA and Advancing Care Information (ACI) is an attestation submitted through a yet-to-be-published portal on the QPP website, QCDR, qualified registry, or EHR.  Each provider can attest to having completed the same CPIA and/or ACI measure(s) but will need to submit their own attestation.

Group Reporting

  • Have to register with CMS as participating in the Group Practice Reporting Option (GPRO) by June 30th of that performance year
  • Payment adjustments will be assessed at the TIN level
  • Under the GPRO, a fraction of a group’s members (dependent upon measures chosen for submission) may dominate the group’s composite score, whereas other members make negligible contributions to the score, but still are subject to the same payment adjustment
  • Can only register as a GPRO if TIN consists of 2 or more ECs
  • If participating in MIPS as a GPRO with 100 or more ECs, then participation in Consumer Assessment of Healthcare Providers and Systems (CAHPS) is required
  • If clinicians participate as a group, they are assessed as a group across all MIPS performance categories
  • Group practices will be treated as non-patient facing as long as more than 75% of the NPIs billing under the group’s TIN meet the definition of a non-patient facing individual MIPS EC

As always, ADVOCATE will keep you up to date on this and all issues impacting radiology as they become available.

Best regards,
Lauren Sloan, RD, LD, MHA
Process Improvement Specialist