September 2021 MACRA Minute

MIPS Facility-Based Scoring Isn’t Available for Performance Year (PY) 2021

In response to the impact of the ongoing COVID-19 public health emergency (PHE), the Centers for Medicare & Medicare Services (CMS) finalized a measure suppression policy in the Fiscal Year (FY) 2022 Inpatient Prospective Payment System (IPPS)/Long-Term Care Hospital (LTCH) PPS final rule for several hospital reporting programs, including the Hospital Value-Based Purchasing (VBP) Program. This policy allows CMS to suppress the use of measure data if the agency determines that circumstances caused by the COVID-19 PHE have affected those measures and the resulting quality scores significantly. CMS also finalized the suppression of 7 measures for the FY 2022 Hospital VBP Program under this policy.

CMS believes that calculating a total performance score in the Hospital VBP Program for hospitals using only data from the remaining measures, all of which are in the Clinical Outcomes Domain, wouldn’t result in a fair national comparison. Therefore, CMS finalized a special scoring policy for FY 2022 that won’t calculate a total performance score for any hospital for FY 2022.

How does this affect MIPS facility-based scoring in PY 2021?

CMS uses the total performance score from the Hospital VBP Program to calculate Merit-based Incentive Payment System (MIPS) facility-based scores for facility-based clinicians and groups in the quality and cost performance categories. The FY 2022 total performance score is what CMS would use to determine these scores for the 2021 MIPS performance year.

  • Because the FY 2022 total performance score from the Hospital VBP Program won’t be available, CMS won’t be able to calculate MIPS facility-based scores for the 2021 MIPS performance year.

What does this mean for MIPS reporting?

Facility-based clinicians and groups will need to submit data on MIPS quality measures (except for administrative claims-based measures that have a benchmark, which are automatically calculated for clinicians and groups that meet the case minimum) to receive a score other than zero for the quality performance category.

CMS will automatically calculate a score for the cost performance category for facility-based clinicians and groups that meet the case minimum for at least one MIPS cost measure; there aren’t any data collection or submission requirements for the cost performance category. If the facility-based clinician or group doesn’t meet the case minimum for any cost measures, the cost performance category will be reweighted to 0% and the weight redistributed to other performance categories.

  • Facility-based clinicians and groups without available and applicable measures can request performance category reweighting by submitting an extreme and uncontrollable circumstances (EUC) application.
  • Please be sure to cite “COVID-19” as the triggering event, as the decision to suppress measures in the Hospital VBP Program was in response to the COVID-19 PHE.

Additional Resources

Update: 2020 MIPS Performance Feedback, Final Score, and 2022 MIPS Payment Adjustment Information

The Centers for Medicare & Medicare Services (CMS) will be updating the Merit-based Incentive Payment System (MIPS) performance feedback and final scores for some clinicians for performance year 2020 and the associated MIPS payment adjustment information for payment year 2022.

CMS is committed to ensuring transparency in the program and alerting clinicians as soon as possible when issues are discovered. CMS’ intention is to provide clinicians advanced notice that they may see some change to their current final scores and payment adjustment information. Additionally, because of these expected changes, CMS will also be extending the targeted review period. More details about what will change from the initial release, who is impacted and how this will affect MIPS payment adjustments, as well as the new targeted review period deadline are coming soon. We appreciate your patience as we work to confirm the information provided is accurate.


Additional Resources:

You can view your current MIPS performance feedback, final score, and payment adjustment on the Quality Payment Program website.  Please note the information you see now may be changing.

You can access your 2020 MIPS performance feedback, 2020 final score, and 2022 payment adjustment information by:

  • Going to cms.gov/login
  • Logging in using your HCQIS Access Roles and Profile (HARP) system credentials; these are the same credentials that allowed you to submit your 2020 MIPS data

If you don’t have a HARP account, please refer to the Register for a HARP Account and Connect to an Organization documents in the QPP Access User Guide and start the process now.

For Shared Savings Program ACOs, please note that beginning August 5, 2021, you will be able to create a HARP account and manage your account in the ACO Management System (ACO-MS). Contact your ACO to find out how you can obtain a HARP account via ACO-MS. If you have any questions, please contact the ACO Information Center at SharedSavingsProgram@cms.hhs.gov or 1-888-734-6433 (Option 1).

To learn more about the information in your performance feedback, review the following 2020 MIPS Performance Feedback Resources:  

MIPS Eligible Clinicians Participating in MIPS Alternative Payment Model (APM) Entities

Individual clinicians and representatives of APM Entities will also be able to access performance feedback directly on the Quality Payment Program website using their HARP account. Note: Performance feedback is not related to model-specific requirements and assessments outside of the Quality Payment Program.  

Questions?

Contact the Quality Payment Program at 1-866-288-8292 or by e-mail at: QPP@cms.hhs.gov. To receive assistance more quickly, please consider calling during non-peak hours—before 10:00 a.m. and after 2:00 p.m. ET. Customers who are hearing impaired can dial 711 to be connected to a TRS Communications Assistant.

Submit Comments on Policy Changes for Quality Payment Program in 2022 Physician Fee Schedule Proposed Rule

Provide Feedback on Proposed Changes to the Quality Payment Program by September 13

The Centers for Medicare & Medicaid Services (CMS) recently issued its proposed policies for the 2022 performance year of the Quality Payment Program (QPP) via the Medicare Physician Fee Schedule (PFS) Notice of Proposed Rule Making (NPRM). The deadline to submit comments on the proposed rule is September 13, 2021.

Highlights

The following are some of the key QPP policies that have been proposed in the NPRM:

  • MIPS Value Pathways (MVPs) begin in 2023 with 7 options for the first year
  • The CMS Web Interface extends as a collection type and submission type for quality measure reporting into the 2022 and 2023 performance years for Shared Savings Program Accountable Care Organizations (ACOs) (for other ACOs and registered groups and virtual groups the CMS Web Interface continues for the 2022 performance period only)
  • Updates to cost measures and improvement activities inventory
  • Revisions to Promoting Interoperability performance category reporting requirements

CMS is also seeking comment on a variety of potential changes in the NPRM, including:

  • Traditional MIPS sunsets after the end of the 2027 performance and data submission periods;
  • The development of new cost measures by stakeholders;
  • The appropriate number of procedures done or conditions treated at the facility types for which CMS is proposing to add affiliation; and
  • The types of utilization data that could be added to Care Compare to inform patients’ healthcare decisions.

Submit a Formal Comment by September 13

You must officially submit your comments in one of the following ways:

  • Electronically, through regulations.gov
  • Regular mail
  • Express or overnight mail
  • Hand or courier

Electronic comments are due no later than 11:59 p.m. ET on September 13, 2021, and mailed comments must be received by 5:00 p.m. ET, September 13, 2021.

For More Information

Learn more about the 2022 PFS NPRM and the Quality Payment Program proposals by reviewing the following resources:

  • 2022 QPP Proposed Rule Resources:
    • Overview Fact Sheet – Offers an overview of QPP’s proposed policies for 2022
    • Comparison Table – Compares 2022 NPRM proposals to the current policies in 2021
    • MVPs Proposals Table – Provides an overview of the proposed policies in the 2022 NPRM related to MVPs
  • MVP Transition Timeline for Comment Solicitation – Provides a visual display of a timeline for transitioning from traditional MIPS to MVPs that CMS is seeking comment on in the 2022 PFS proposed rule.

Questions

Contact the Quality Payment Program at 1-866-288-8292 by e-mail at: qpp@cms.hhs.gov. To receive assistance more quickly, consider calling during non-peak hours—before 10 a.m. and after 2 p.m. Eastern Time (ET). Customers who are hearing impaired can dial 711 to be connected to a TRS Communications Assistant.

Now Available: 2022 CMS QRDA III Implementation Guide, Schematron, and Sample Files for Eligible Clinicians and Eligible Professionals Programs

The Centers for Medicare & Medicaid Services (CMS) has published the 2022 CMS Quality Reporting Document Architecture (QRDA) Category III Implementation Guide (IG), Schematron, and Sample Files for Eligible Clinicians and Eligible Professionals Programs. The 2022 CMS QRDA III IG outlines requirements for eligible clinicians and eligible professionals to report electronic clinical quality measures (eCQMs) for the calendar year (CY) 2022 performance period for these programs:

  • Quality Payment Program: Merit-based Incentive Payment System (MIPS) and Alternative Payment Models
  • Primary Care First
  • Medicaid Promoting Interoperability

The 2022 CMS QRDA III IG contains these high-level changes, as compared with the 2021 CMS QRDA III IG:

  • Guidance and conformance statements related to the Comprehensive Primary Care Plus quality reporting has been removed.
  • Updates to Table 14 to include the universally unique identifier list for the MIPS CY 2022 performance period eCQM specifications for eligible clinicians and eligible professionals.

Changes to the 2022 CMS QRDA III Schematron:

  • The schematron has been updated to support conformance statement updates as outlined in this version of the IG.

Changes to the 2022 CMS QRDA III Sample Files:

  • Sample files have been updated to support updates as outlined in this version of the IG.

Please note: CMS will release a subsequent publication based on the publication of the 2022 Physician Fee Schedule Final Rule in fall 2021. Updated measure tables and other content may change in the IG based on the publication of the Final Rule.

Additional QRDA-Related Resources:

Find additional QRDA-related resources, as well as current and past IGs, on the Electronic Clinical Quality Improvement (eCQI) Resource Center QRDA page. For questions related to this guidance, the QRDA IGs, or Schematrons, visit the ONC Project Tracking System (Jira) QRDA project. See the QRDA Known Issues Dashboard for solutions under development for both QRDA I and III known technical issues. These known issues supplement the information in QRDA IGs and other supporting documents.

Now Available: Updated eCQM DERep for CY 2022 Reporting and Performance Periods

The Centers for Medicare & Medicaid Services (CMS) has updated the Electronic Clinical Quality Measure (eCQM) Data Element Repository (DERep) to provide information for eCQMs used in CMS quality reporting and incentive programs for the calendar year (CY) 2022 reporting and performance periods. The eCQM DERep provides information on the data elements associated with eCQMs and their definitions. Each data element also includes the associated value set or the direct reference code (DRC), the Quality Data Model (QDM) datatype, the QDM attributes, and QDM entities used by that data element. The intent of the eCQM DERep information is to improve clarity for those implementing eCQMs.

Please send any comments, suggestions, or questions regarding the eCQM DERep to ecqi-resource-center@hhs.gov. For more information on eCQM development and implementation, see the Electronic Clinical Quality Improvement (eCQI) Resource Center.

September Telligen QPP Connect Live Call

As part of the Performers of Excellence Award program, we are hosting a call-in series called Telligen QPP Connect Live! Each month we highlight a topic with a few slides to kick off the call/start the conversation and then you can ask questions (on the topic or anything else you would like). The next call is scheduled for Wednesday, September 22nd from 12:00 – 1:00 Central. On September’s call we will review how to prepare for 2021 MIPS data submission. As always, we will have time at the end of the presentation for any MIPS questions you have. Please join us on Wednesday, September 22nd at noon CST using the link below.

Join Zoom Meeting

https://telligen.zoom.us/j/99104893418?pwd=MFRNZWdOV3ZwaEQ3VkQ3aDJidWJIZz09

Meeting ID: 991 0489 3418

Passcode: 784640

One tap mobile

+19294362866,,99104893418# US (New York)

+16699006833,,99104893418# US (San Jose)

Dial by your location

        +1 929 436 2866 US (New York)

        +1 669 900 6833 US (San Jose)

        877 853 5257 US Toll-free

        888 475 4499 US Toll-free

Meeting ID: 991 0489 3418

CMS Webinars

Reminder you can view previous CMS webinars on various MIPS categories in the Webinar Library on the QPP website. The 2022 Quality Payment Program Proposed Rule Overview Webinar is now posted with recording and slides available.

Telligen Webinars

Our monthly webinar for August provided details on the 2020 MIPS Performance Feedback Reports. You can view the recording or download the slides from our website.

New Resources in the QPP Resource Library

The following resources were updated or added in August:

2021 MIPS Extreme and Uncontrollable Circumstances Exception Application Guide

2021 MIPS Automatic Extreme and Uncontrollable Circumstances Policy Fact Sheet

2021 MIPS Cost User Guide

2021 MIPS Quality User Guide

2021 Quality Quick Start Guide

2021 Facility-Based Quick Start Guide

MIPS Value Pathways Overview Fact Sheet

2021 Quality Payment Program Final Rule Resources

2021 MIPS Overview Quick Start Guide

2021 MIPS Eligibility and Participation User Guide

2021 Improvement Activities Quick Start Guide

2021 MIPS Improvement Activities User Guide

2021 Promoting Interoperability Quick Start Guide

2021 MIPS Promoting Interoperability User Guide

2021 Cost Quick Start Guide

2022 Quality Payment Program Proposed Rule Resources

2022 Quality Payment Program Proposed Rule Overview Fact Sheet

MVP Transition Timeline for Comment Solicitation

2021 MIPS Cost Measure Codes Lists

2022 MIPS Payment Year Payment Adjustment User Guide

2021 CAHPS for MIPS and CAHPS for ACOS Approved Survey Vendors

2020 Performance Period Benchmarks

Quality Payment Program Access User Guide

2021 Traditional MIPS Scoring Guide

Draft COVID-19 Vaccination Measure Specifications

2020 MIPS Performance Feedback FAQs

2021 EMA and Denominator Reduction Guide

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