January 2021 MACRA Minute

Quality Payment Program SURS Initiative Ending

Over the past 5 years, the Centers for Medicare & Medicaid Services (CMS) has successfully implemented a technical assistance initiative for clinicians in small practices participating in the Quality Payment Program (QPP) known as the Small, Underserved, and Rural Support (SURS). This initiative provides free, customized technical assistance to practices with 15 or fewer Merit-based Incentive Payment System (MIPS) eligible clinicians. Since QPP began in 2017, SURS technical assistance organizations have provided direct support to an average of 107,250 clinicians annually and achieved a 99% average annual small practice clinician satisfaction rate for the technical assistance received based on an average of 19,281 responses. Overall, the feedback from clinicians that have worked with SURS technical assistance organizations has been overwhelmingly positive and shows the strong impact this initiative has had on small practice clinicians’ participation in QPP.

As clinicians are preparing for the start of the 2022 performance year (PY), it is important to note that the SURS initiative will end on February 15, 2022as the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) only provided for 5 years of direct support. The practice-level program support provided by the external technical assistance organizations will no longer be available after this date. For those currently receiving MIPS support from the SURS technical assistance organizations, be assured that these organizations have committed to providing exceptional technical assistance organizations through February 15th. CMS encourages small practices to take advantage of this initiative within the remaining time. 

CMS is committed to providing continued support and educational resources for small, underserved and rural practices participating in QPP and will continue to have the following options available:

  • The Quality Payment Program Service Center will serve as a primary point of contact to help address your questions and concerns. The Service Center is able to address basic questions as well as more complex scenarios.
  • Connect with the Service Center at 1-866-288-8292 (TTY 1-877-715-6222) or via email at QPP@cms.hhs.gov Monday – Friday 8 am – 8 pm ET
  • The QPP website provides a centralized location for resources, and specifically, the Support for Small Practices page will provide updates and resources for small practices.
  • All small, underserved and rural clinicians and their staff are encouraged to bookmark this page (https://qpp.cms.gov/resources/small-underserved-rural-practices) for easy access to updates and available resources.
  • Upcoming Webinars and trainings will be listed on the QPP Webinar Library. Recordings, slides and transcripts of past events will also be available and posted to the Webinar Library.
  • The QPP listserv to receive updates on the Quality Payment Program and upcoming program deadlines.
  • Please encourage your fellow small, underserved and rural clinicians and their staff to sign up for the QPP listserv by entering their email address into the box at the bottom of any qpp.cms.gov webpage.
  • CMS is also looking into the possibility of creating a targeted listserv focused on small practices so that you can get the information you need most.

What Should I Do Now?

  1. Bookmark the QPP website Support for Small Practices page.
  2. Sign-up for the QPP listserv.
  3. Small practices participating in QPP for PY 2021 should make plans to submit data early while technical assistance support is still available. The data submission window for PY 2021 opens on January 3, 2022 and closes on March 31, 2022.

CMS understands clinicians in small practices, including those in rural locations, health professional shortage areas, and medically underserved areas are a vital part of our healthcare system. Therefore, CMS remains committed to providing educational resources to help maximize participation in QPP beyond the end of the SURS initiative on February 15, 2022. CMS is working with the SURS technical assistance organizations to identify areas where greater support is needed for small practices in order to improve existing resources or develop new resources as feasible and ensure small practices continue to be successful in QPP.


MIPS 2021 Data Submission Period is Now Open

MIPS Eligible Clinicians Can Start Submitting Data for 2021 through March 31

CMS has opened the data submission period for Merit-based Incentive Payment System (MIPS) eligible clinicians who participated in the 2021 performance year of the Quality Payment Program (QPP). Data can be submitted and updated from now until 8:00 p.m. ET on March 31, 2022.

How to Submit Your 2021 MIPS Data

Clinicians will follow the steps outlined below to submit their data:

  1. Go to the Quality Payment Program webpage.
  2. Sign in using your QPP access credentials (see below for directions).
  3. Submit your MIPS data for the 2021 performance year or review the data reported on your behalf by a third party.

How to Sign In to the Quality Payment Program Data Submission System

To sign in and submit data, clinicians will need to register in the HCQIS Authorization Roles and Profile (HARP) system. For clinicians who need help enrolling with HARP, please refer to the Quality Payment Program Access User Guide.

Note: Clinicians who are not sure if they are eligible to participate in the Quality Payment Program can check their final eligibility status using the QPP Participation Status Tool. Clinicians and groups that are opt-in eligible will need to make an election before they can submit data. (No election is required for those who don’t want to participate in MIPS.)

If you are in a small practice (15 or fewer clinicians) and need help from our Small, Underserved, and Rural Support (SURS) technical assistance organizations to submit your data, CMS encourages you to reach out early in the data submission period. The SURS initiative will be ending on February 15, 2022, and this support will no longer be available after that date.

For More Information

To learn more about how to submit data, please review the following resources available on the QPP Resource Library:

Additional resources will be posted to the Resource Library later this month. You may also contact the Quality Payment Program at 1-866-288-8292 or by e-mail at: QPP@cms.hhs.gov.


2022 MIPS Payment Adjustments in Effect Based on 2020 Performance

In Summer 2021, each Merit-based Incentive Payment System (MIPS) eligible clinician received a 2020 MIPS final score and associated payment adjustment factor(s) as part of their 2020 MIPS performance feedback, available on the Quality Payment Program website

2022 MIPS payment adjustments, based on each MIPS eligible clinician’s 2020 MIPS final score, will now be applied to payments made for Part B covered professional services payable under the Physician Fee Schedule. Payment adjustments are determined by the final score associated with your Taxpayer Identification Number (TIN)/National Provider Identifier (NPI) combination.

MIPS eligible clinicians, identified by TIN/NPI combination for the 2020 performance period, will receive a positive, neutral, or negative MIPS payment adjustment in 2022 if they:

  • Were a clinician type that was included in MIPS;
  • Enrolled in Medicare prior to January 1, 2020;
  • Were not a Qualifying Alternative Payment Model (APM) Participant (QP);
  • Were a Partial Qualifying APM Participant (Partial QP) that elected to participate in MIPS as a MIPS eligible clinician; and
  • Met one of the following criteria:
  • Individually exceeded the low-volume threshold;
  • Were in a practice that exceeded the low-volume threshold at the group level and submitted group data or were part of an approved virtual group; or
  • Were in a MIPS APM and the APM Entity group exceeded the low volume threshold (This also includes Partial QPs who elected to participate in MIPS).

For More Information

Visit the Quality Payment Program Resource Library for the 2022 MIPS Payment Adjustment User Guide and more Quality Payment Program resources. For questions, contact the Quality Payment Program at 1-866-288-8292, Monday through Friday, 8:00 AM-8:00 PM ET or by e-mail at: QPP@cms.hhs.gov. Customers who are hearing impaired can dial 711 to be connected to a TRS Communications Assistant.


QPP Service Center Hold Times Expected to Increase

The Quality Payment Program (QPP) Service Center is projecting an increase in volume of calls and emails between January and March 2022 due to the opening of 2021 MIPS data submission period. The increase in call volume and emails will result in longer wait times.

In order to reduce wait times and ensure successful 2021 submission, CMS recommends taking the following actions:

  • Use One Method to Report Issues — Due to the increase in volume at the QPP Service Center and to minimize backlog, CMS requests that you use only one method of reporting for the same issue (email or phone). Note: Cases are processed in the order in which they are received regardless of the manner in which the Service Center was contacted. Please allow time for processing.
  • Submit Your Data Early — It is encouraged that you submit your 2021 MIPS performance year data early during the submission period as this allows you plenty of time for any necessary Service Center assistance.
  • Call the Service Center at Off-Peak Hours — CMS strongly recommends calling the Service Center during off-peak hours (8:00 AM-10:00 a.m. ET OR 2:00 p.m.-8:00 p.m. ET).

For More Information

Visit the QPP Resource Library to review new and existing QPP resources. Contact the Quality Payment Program at 1-866-288-8292 or by e-mail at: QPP@cms.hhs.gov. Customers who are hearing impaired can dial 711 to be connected to a TRS Communications Assistant.


2021 Performance Period Suppressed Merit-based Incentive Payment System (MIPS) Quality Measures

Policies on Suppressing Certain Quality Measures

The following measures are excluded from a MIPS eligible clinician’s total measure achievement points and total available measure achievement points: (i) each submitted CMS Web Interface-based measure that meets the data completeness requirement, but does not have a benchmark or meet the case minimum requirement, or is redesignated as pay-for-reporting for all Shared Savings Program accountable care organizations by the Shared Savings Program; and (ii) each administrative claims-based measure that does not have a benchmark or meet the case minimum requirement. 42 C.F.R. § 414.1380(b)(1)(i)(A)(2).

Beginning with the 2019 MIPS performance period, for each measure that a MIPS eligible clinician submits that is significantly impacted by clinical guideline changes or other changes that CMS believes may result in patient harm or misleading results, the total available measure achievement points are reduced by 10 points. 42 C.F.R. § 414.1380(b)(1)(vii)(A).

Quality Measure Number/TitleCollection Type ImpactedSuppression Rationale
Measure 001: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)Medicare Part B ClaimsQuality Measure Implementation Resulting in Misleading Result: The 2021 Medicare Part B Claims measure specification includes quality data codes (3051F and 3052F) that were not activated during the annual Current Procedural Terminology (CPT) Category II update process.

Suppression Rationale: Due to the inactive quality data codes and the subsequent inability to report such codes, CMS determined that this measure has undergone a significant change that may result in misleading results. Without these available numerator options, the measure will not allow clinicians to report the numerator of the measure appropriately and will hold clinicians, groups, and/or virtual groups accountable for performance that may not be reflective of the actual care provided. Therefore, this measure will be suppressed within the Medicare Part B Claims collection type in accordance with § 414.1380(b)(1)(vii)(A).
Measure 111: Pneumococcal Vaccination Status for Older AdultsMedicare Part B Claims
MIPS Clinical Quality Measure (CQM)
Electronic Clinical Quality Measure (eCQM)
Updated Guidelines: Guidelines have been revised to allow 20-valent pneumococcal conjugate vaccine by itself or the 15-valent vaccine followed by the 23-valent vaccine for adults aged 65 years or older who have not received a pneumococcal conjugate vaccine before — or whose vaccination status is unknown — and people aged 19 to 64 years who have an underlying medical condition or other risk factors and who also have not received a pneumococcal vaccine.

Truncation Rationale: Due to the updated guidelines allowing the use of 15 – or 20-valent pneumococcal conjugate vaccine, this measure will likely produce misleading results for the last quarter of the performance period. The current measure specifies that only PCV13 or PPSV23 vaccine (or both) will meet the quality action. Therefore, this measure will be truncated to the first 9 months of the performance period for the Medicare Part B claims and MIPS CQM collection types in accordance with § 414.1380(b)(1)(vii)(A).
Measure 117: Diabetes: Eye ExamMedicare Part B ClaimsQuality Measure Implementation Resulting in Misleading Result: The 2021 Medicare Part B Claims measure specification includes quality data codes (2023F, 2025F, and 2033F) that were not activated during the annual Current Procedural Terminology (CPT) Category II update process.

Suppression Rationale: Due to the inactive quality data codes and the subsequent inability to report such codes, CMS determined that this measure has undergone a significant change that may result in misleading results. Without these available numerator options, the measure will not allow clinicians to report the numerator of the measure appropriately and will hold clinicians, groups, and/or virtual groups accountable for performance that may not be reflective of the actual care provided. Therefore, this measure will be suppressed within the Medicare Part B Claims collection type in accordance with 42 CFR § 414.1380(b)(1)(vii)(A).
Measure 128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up PlaneCQMQuality Measure Implementation Resulting in Misleading Result: During the 2021 performance period, a misalignment was identified between the numerator header in the measure narrative and the numerator logic. Due to a change in the CQL, the timing for documenting the quality action changed and, according to the CQL definition, may in some circumstances extend beyond the end of the measurement period. Clinicians, groups, and/or virtual groups may submit data per the defined time except when the quality action takes place beyond the end of the performance period.

Suppression Rationale: Due to the inability to accurately submit the quality action and the misalignment between the measure narrative and logic, CMS determined that this measure has undergone a significant change that may result in misleading results. Due to the logic revisions, clinicians, groups, and/or virtual groups will not receive credit for a follow-up plan documented in PY2022 and would fail the measure because reporting would show as no follow-up documented. Therefore, this measure will be suppressed within the eCQM collection type in accordance with 42 CFR § 414.1380(b)(1)(vii)(A).
Measure 134: Preventive Care and Screening: Screening for Depression and Follow-Up PlanCMS Web InterfaceQuality Measure Implementation Resulting in Misleading Results: CMS determined that coding changes made to the 2021 PREV-12 were substantive changes to the measure. The modifications removed the Systematized Nomenclature of Medicine (SNOMED) codes that recognized the rescreening of a patient using an additional standardized depression screening tool as a means of meeting the performance criteria for implementing an appropriate follow-up plan specific to a patient with a positive depression screening.

Suppression Rationale: The coding changes no longer allow clinicians to meet the performance criteria of implementing a follow-up plan without providing an appropriate follow-up plan to the patient (patient would not be eligible for the measure numerator). For the 2021 performance period, the following will apply to the PREV-12 measure: Excluded from the Merit-based Incentive Payment System (MIPS) scoring in accordance with §414.1380(b)(1)(i)(A)(2)(i) provided that the measure meets the data completeness requirement and the data applicable to the measure is reported via the CMS Web Interface.

Contact the Quality Payment Program at 1-866-288-8292 or by e-mail at: QPP@cms.hhs.gov (Monday-Friday 8 a.m.- 8 p.m. Eastern Time [ET]). 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.


CMS Approves Performance Period Truncation of the 2021 Performance Period for Quality Measure #111: Pneumococcal Vaccination Status for Older Adults Merit-based Incentive Program (MIPS) Clinical Quality Measure (CQM), Medicare Part B Claims, and Electronic Clinical Quality Measure (eCQM) Collection Types to the First 9 Months of Data

CMS will truncate the performance period to the first 9 months of data for the Medicare Part B claims, MIPS clinical quality measure (CQM), and electronic clinical quality measure (eCQM) collection types for measure Q111: Pneumococcal Vaccination Status for Older Adults.

At the October 20, 2021 meeting, the Advisory Committee on Immunization Practices (ACIP) approved, by majority vote, to update the pneumococcal vaccine recommendations. The revised recommendation no longer aligns with the current posted measure specifications for the Medicare Part B claims, MIPS CQM, and eCQM collection types, as numerator compliance is achieved through administration or previous receipt of either the pneumococcal conjugate vaccine (PCV) 13 or pneumococcal polysaccharide vaccine (PPSV23) vaccine (or both). ACIP now recommends:

  • Adults 65 and older with no previous receipt of or unknown status of vaccination should receive the PCV20 or PCV15 vaccine.
    • If PCV15 is administered, this should be followed by a dose of PPSV23.
  • Adults aged 19 – 64 with certain underlying conditions of risk-factors with no previous receipt of or unknown status of vaccination should receive the PCV20 or PCV15 vaccine.
    • If PCV15 is administered, this should be followed by a dose of PPSV23.

Therefore, CMS is truncating the performance period for the Medicare Part B claims, MIPS CQM, and eCQM collection types for this measure to the first 9 months of data in accordance with § 414.1380(b)(1)(vii)(A). MIPS eligible clinicians do not need to submit any additional documentation, and CMS will assess the measure for these collection types based upon the first 9 months of data.


CMS Publishes 2022 PFS Final Rule for the Quality Payment Program

The Centers for Medicare & Medicaid Services (CMS) published the CY 2022 Medicare Physician Fee Schedule (PFS) Final Rule, which includes the final policies for the 2022 performance year of the Quality Payment Program (QPP). The rule affects traditional MIPSMIPS Value Pathways (MVPs), the APM Performance Pathway (APP)Advanced APMs, and the Medicare Shared Savings Program (Shared Savings Program).

2022: QPP Final Rule Highlights

Key QPP policies in the 2022 performance year include:

  • Revising the definition of a MIPS eligible clinician to include social workers and certified nurse mid-wives.
  • Setting the MIPS performance threshold at 75 points and the exceptional performance threshold at 89 points.
  • Weighting the cost and quality performance categories equally (as statutorily required) at 30%.
  • Extending the CMS Web Interface as a collection type and submission type in traditional MIPS for registered groups, virtual groups, and APM Entities for the 2022 performance year only.
  • Finalizing a longer transition for electronic clinical quality measures (eCQMs)/MIPS clinical quality measures (CQMs) measure reporting for Shared Savings Program Accountable Care Organizations (ACOs) by extending the CMS Web Interface as an option for 3 years (through the 2024 performance year).

2023 and Beyond: QPP Final Rule Highlights – Additional Finalized Policies

The following updates were also included in the PFS Final Rule and affect future years of the QPP:

  • Finalizing 7 MVPs that will be available, beginning with the 2023 performance year.
  • Providing a description of the registration process and timeline for MVP and subgroup registration, beginning with the 2023 performance year.

For More Information

To learn more about the CY2022 PFS Final Rule and all of the 2022 QPP finalized policies, please review the following resources:

  • Press Release: Provides additional details regarding the announcement.
  • QPP 2022 Final Rule Resources Zip FileContains the following:
    • Overview Fact Sheet: Offers an overview of the QPP Final Rule policies for the 2022 performance year.
    • Policies Comparison Table: Compares the final 2022 performance year policies to the requirements for the 2021 performance year.
    • MVP Policies Table: Provides an overview of the policies for implementation of MVPs beginning in the 2023 performance year.
    • Frequently Asked Questions (FAQs): Addresses the FAQs for the 2022 QPP Final Rule policies.

Questions

Contact the Quality Payment Program at 1-866-288-8292 (Monday-Friday, 8 a.m.- 8 p.m. ET) or 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. ET. Customers who are hearing impaired can dial 711 to be connected to a TRS Communications Assistant.


Check Your Initial 2022 MIPS Eligibility on the QPP Website

You can now use the Quality Payment Program Participation Status Tool to check your initial 2022 MIPS eligibility status.

  • Just enter your National Provider Identifier (NPI) to find out whether you need to participate in MIPS during the 2022 performance year.

Low-Volume Threshold Requirements

To be eligible to participate in MIPS in 2022, you must:

  • Bill more than $90,000 a year in allowed charges for covered professional services under the Medicare Physician Fee Schedule (PFS); AND
  • Furnish covered professional services to more than 200 Medicare Part B beneficiaries; AND
  • Provide more than 200 covered professional services under the PFS.

If you don’t exceed all 3 of the above criteria for the 2022 performance year, you’re excluded from MIPS. However, you have the opportunity to opt-in to MIPS and receive a payment adjustment if you meet or exceed 1 or 2, but not all, of the low-volume threshold criteria. Alternatively, you may choose to voluntarily report to MIPS and not receive a payment adjustment if you don’t meet any of the low-volume threshold criteria or if you meet some, but not all, of the criteria.

Please note, CMS now evaluates the low-volume threshold for MIPS Alternative Payment Model (APM) participants at the individual or group level, just as it does for participants who aren’t in MIPS APMs. CMS no longer evaluates APM Entities for eligibility against the low-volume threshold.

Find Out Today

Find out today whether you’re eligible for MIPS. Prepare now to earn a positive payment adjustment in 2024 for your 2022 performance.

Note: The QPP Participation Status Tool will be updated with clinicians’ QP status 3 times during the performance year.

Questions?

Please contact the Quality Payment Program at 1-866-288-8292 (Monday-Friday 8 a.m.- 8 p.m. ET) or 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. ET. Customers who are hearing impaired can dial 711 to be connected to a TRS Communications Assistant.


2021 MIPS Data Submission Overview: An Upcoming Web Event

You are invited to attend the 2021 MIPS Data Submission Overview web event to learn how to submit your 2021 MIPS data. The MIPS data submission can be anxiety inducing, so the goal of this event is to help you feel confident with your 2021 MIPS data submission. Please join to discuss how to prepare and what to expect.

Participants will learn about:

  • Preparation
    • HARP account
    • Documentation
    • Vendor requirements
  • Data Submission
    • Submission types
    • Step by step instructions
    • Retain documentation

This event is designed and ideal for:

  • MIPS-eligible clinicians from solo and small group practices with 15 or fewer clinicians
  • Practice managers and staff from small group practices tasked with submitting MIPS data and/or persons supporting small group practices that are preparing for MIPS data submission

To register for the event, click on one of the links provided below:

Tuesday, January 18th

3:30 PM-4:30 PM (Eastern Time)

or

Thursday, January 20th

11:00 AM to Noon (Eastern Time)


January Telligen QPP Connect Live Call

As part of Telligen’s 2021 Performers of Excellence (PoE) award program, we hosted a call-in series called Telligen QPP Connect Live! Each month in 2021 we highlighted a topic with a few slides to kick off the call/start the conversation and then you asked questions. The final call to highlight those who performed well for the PoE award Program in 2021 will be Wednesday, January 19, 2022, at noon CST using the link below. We will also talk about some common data submission questions for the 2021 MIPS performance year.

  • 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

Reminder you can view recordings or download slides from previous Telligen webinars from our website.


CMS Webinars

Reminder you can view previous CMS webinars on various MIPS categories/topics in the Webinar Library on the QPP website. The recordings and slides from the 2022 Quality Payment Program Final Rule and 2022 MVP Development Kick-off webinars are now available.


New Resources in the QPP Resource Library

The following resources were updated or added in December:

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