MACRA Minute June 2020

New COVID-19 Response Webpage

CMS has added a new page to the QPP Website for information about changes to the MIPS program due to the COVID-19 pandemic. You can find the site here. Please reach out to us if you have any questions about these program changes; we would be happy to assist you.

2019 Performance Period Suppressed MIPS Quality Measures

In the Calendar Year (CY) 2019 Physician Fee Schedule Final Rule (83 FR 59847), the Centers for Medicare & Medicaid Services (CMS) established a policy that provides for the suppression of measures in certain circumstances.  Starting with the 2019 performance period, for measures significantly impacted by clinical guideline changes or other changes where CMS believes that adherence to guidelines in the existing measures could result in patient harm or otherwise cause misleading results as to what is measured as good quality of care, CMS will reduce the denominator of available measure achievement points for the quality performance category by 10 points for each impacted measure that is submitted by MIPS eligible clinicians and groups.  Such policy will “hold harmless” any clinician or group submitting data on a suppressed measure.

Measures affected by this policy in 2019 are: Measure 69: Hematology: Multiple Myeloma: Treatment with Bisphosphonates, when reported via MIPS CQM; Measure 110: Preventive Care and Screening: Influenza Immunization, when reported via Medicare Part B Claims, MIPS CQM, eCQM, CMS Web Interface; Measure 450: Trastuzumab Received By Patients With AJCC Stage I (T1c) – III And HER2 Positive Breast Cancer Receiving Adjuvant Chemotherapy, when reported via MIPS CQM. Measure 134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan, when reported via eCQM.

Do You Know If Your Quality Measures are Topped Out and/or Capped at 7 Points?

Did you expect a higher Quality score on your preliminary feedback report after submitting your 2019 MIPS data? Perhaps one or more of your quality measures are ‘topped out’ so you didn’t score 10 points for 100% performance rate like you thought you would. This happens when a large percentage of clinicians in the historical benchmark data set had the maximum achievable performance rate. These clinicians perform so well that this measure is considered ‘topped out’. You can find the historical benchmark data here in the 2020 Quality Benchmarks file.

What Are Quality Measure Benchmarks?

Quality measure benchmarks are the point of comparison CMS uses to score the measures you submit. When you submit measures for the Quality performance category, your performance on each measure is assessed against its benchmark to determine how many points the measure earns.

  • CMS compares your performance on the measure to its benchmark.
  • CMS assigns anywhere from 3 to 10 achievement points for each MIPS measure that meets the data completeness standards and case minimum requirements based on this comparison.
  • Measures may also be eligible for bonus points, in addition to these achievement points.

Are All Topped Out Measures Capped At 7 Points?

No. A measure is capped at 7 points when it is topped out through the same collection type for 2 consecutive years. The 7-point cap is applied in the second year the measure is identified as topped out. A measure may be topped out without being capped at 7 points.

A “Y” (for “YES”) in the Seven Point Cap column (column P) of the benchmark file indicates the measure is capped at 7 points.

Example 1. Measure ID 104 (MIPS CQM)

A maximum of 10 achievement points is available for the measure.

Topped Out Y

Seven Point Cap N

Example 2. Measure ID 320 (MIPS CQM and Medicare Part B Claims Measure)

A maximum of 7 achievement points is available for the measure, even if your performance rate is found in Deciles 7 – 10.

Topped Out Y

Seven Point Cap Y

PI Hardship Exception Application Is Now Open For 2020

If you have any of the following circumstances, you may qualify for a re-weighting of the Promoting Interoperability performance category (to 0%): 

  • You’re a small practice
  • You have decertified EHR technology
  • You have insufficient Internet connectivity
  • You face extreme and uncontrollable circumstances such as disaster, practice closure, severe financial distress or vendor issues
  • You lack control over the availability of CEHRT

Beginning with performance year 2020, you will need a HCQIS Access Roles and Profile (HARP) account to submit a MIPS Promoting Interoperability Performance Category Hardship Exception Application. Once you sign into QPP with your credentials, select ‘Exceptions Application’ on the left-hand navigation and then select ‘Promoting Interoperability Hardship.’ The online application can be found by logging into your HARP account here. The application will close 12/31/2020. If your application is approved, you do not have to report for the MIPS Promoting Interoperability performance category and the category will be re-weighted to 0% of your final score. The 25% weighting of the Promoting Interoperability performance category will be redistributed to another performance category (or categories) unless you choose to submit data. As with all documentation and data used to attest to MIPS, you would want to keep your approval email for a minimum of six years.

CMS July LAN Webinar

Save the date for the July CMS LAN Webinar, registration and topic are forth coming

  • Tuesday, July 14, 2020, 10:00 a.m. – 11:00 a.m. CT
  • Thursday, July 16, 2020 2:30 p.m. – 3:30 p.m. CT

New Resources in the QPP Resource Library

The following resources were updated or added in May

              2020 MIPS Data Validation Criteria

              Quality Payment Program COVID-19 Response

              2020 QCDRs

              2020 Qualified Registries

              2020 Call for Measures and Activities

New Measures and Activities for 2020

CMS recently added a new Improvement Activity for participation in COVID-19 clinical trials. IA_ERP_3, COVID-19 Clinical Trials, is a high-weighted activity. To receive credit for this activity, you must participate in a COVID-19 clinical trial utilizing a drug or biological product to treat a patient with a COVID-19 infection and report their findings through a clinical data repository or clinical data registry for the duration of the study. For more information on the COVID-19 clinical trials available please visit the U.S. National Library of Medicine website.

Meet Our New Team Member

Hello!  My name is Marlene Hodges, and I am excited to join the Telligen SURS team.  I have been with Telligen for 21 years.  Some of the work I have been involved with during this time includes the QIO, the Health IT Regional Extension Center, a host of smaller contracts, and for the past 2 1/2 years the QPP MIPS Service Center, working on both the education/outreach and technical teams.  I look forward to getting to know continuing QPP work with practices participating in the SURS program. 

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