How to set-up a QPP compliant reporting mechanism

Are you overwhelmed thinking about creating QPP compliant reporting? Well, you’ll be relieved to learn it’s not very different from the way in which you previously reported your data, especially under the Quality category. CMS does require different reporting thresholds and specific information for certain reporting mechanisms, however. You’ll have to capture additional information that was not included, so you’re not totally off the hook.

Quality measures

Under QPP, quality measures account for 60% of the MIPS composite score, so it’s critical to choose and report on the measures that will best fit your practice. Review the quality measures outlined in the MACRA final rule. Select up to six measures and one outcome measure from the approved list of either the individual quality measures for MIPS 2017 reporting or the MIPS 2017 specialty reporting. In doing so, consider what you’ve previously reported for PQRS and the feedback you’ve received. Be careful though that you don’t continue to choose ease of data collection over the value of the score since the importance of the outcome now has a significant impact on your reimbursements. Compare your historical numbers against the benchmarks to gain insight into whether you should keep or replace the measurements in your 2017 reporting.

When it comes to improving performance on a specific measure, you’ll also need to consider the extent to which your existing workflow will need to be improved and the feasibility of implementing and maintaining those modifications. Remember, reporting is required, but your performance in each category is what determines your score. Maximizing your performance and your score is key.

As a rule, all quality measures must be reported in the same manner, so whether that’s Part B claims, EHR, registry, etc., the chosen reporting mechanism will also impact which measures are able to be included.

Advancing care information

The MIPS advancing care information (ACI) category replaces the meaningful use program and accounts for 25% of your MIPS composite score. To meet the requirements of this category, you’ll need an Electronic Health Record (EHR) vendor. If you’re not currently using an EHR product and service, you’ll need to purchase and implement one, but be sure the product you choose is certified. An EHR is certified when it has met the technological capability, functionality, and security requirements required by the Secretary of Health and Human Services and has also received certification by the Office of the National Coordinator (ONC) and CNS. If you already have an EHR vendor, be sure to inquire about their MIPS readiness plan and how they can assist you in your meeting your MIPS objectives.

Four Advancing Care Information measures are required for 2017, and 5 measures each year following. There are 9 additional measures in the Performance Score that are optional and available to earn extra points. With your EHR vendor, it’s critical to discuss the issues of data ownership, commitment to future certification requirements, and public health reporting options. You’ll also need to conduct a security risk analysis each year to ensure the privacy and security of your patients’ health information.

Improvement activities

The Improvement Activities category of MIPS accounts for 15% of the MIPS composite score. It evaluates the degree in which you participate in activities that work to improve your clinical practice. You’ll need to choose from the list of activities in this category and demonstrate your performance in 4 of them over a period of 90 days.

Attesting to improvement activities can be done through your choice of the CMS Quality Payment Program website, a qualified registry or qualified clinical data registry, or your EHR system. This is the simplest form of reporting since you only need to confirm that the activity was completed. You can choose the activities that are most meaningful to your practice since there are no subcategory reporting requirements.

You’ll need to click “Yes” to each activity that meets the 90-day requirement on the CMS Quality Payment Program website or work with your EHR vendor to determine the best way to submit the confirmation of completed activities through a qualified registry, qualified clinical data registry, or EHR.

Regardless of the submission method, the CMS document policy requires you to keep any supporting documentation for 6 years.

Auditing your submitted information

CMS will selectively conduct annual audits to validate data submitted under MIPS, so you should always be prepared for a potential audit. Be sure you’re using EHR templates for your documentation and that they include the required support for each measure. It’s also helpful to keep a record of the patients on whom you report for each measure and the specific time period so they can be easily identified in the case of an audit.


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