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    Avoid the MIPS Penalty Without EHR: Tips for Reporting Via the IRIS Registry

    By Rebecca Hancock, Iris Registry Director, interviewing Belinda Brodoski, CPC, Joyce Hogue, CPC, OCS, and Karen Turkish, RN

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    For ophthalmology, the IRIS Registry has proved to be the tool of choice for reporting in the Merit-Based Incentive Payment System (MIPS). Indeed, it has helped ophthalmology practices avoid nearly $400 million in penalties based on their performance during the 2017 and 2018 MIPS reporting years.

    Why you can’t afford to ignore MIPS. If you don’t participate in MIPS in 2019, your 2021 Medicare Part B payments could be subject to a 7% penalty, which would translate to an estimated $28,161 for the average ophthalmologist.

    If you haven’t already started with this year’s MIPS, you need to get busy. “The sooner you start, the better,” said Karen Turkish, RN, administrator for Lance Turkish, MD, and Associates in New Orleans. Her practice is on paper charts, and they report manually using the IRIS Registry MIPS portal. “When you wait to the end of the year, you are in panic mode,” added Belinda Brodoski, CPC, practice administrator for Eye Clinic of Livonia in Livonia, Michigan.

    Two ways to report MIPS quality measures via the IRIS Registry. The most efficient way to report quality is by integrating your electronic health record (EHR) system with the IRIS Registry to calculate quality measures for MIPS reporting. However, an EHR system is not required for reporting quality measures via the IRIS Registry.

    This article is for manual reporting (no EHR needed.) Hundreds of ophthalmology practices successfully avoid MIPS penalties by manually entering data in the IRIS registry web portal. Some of these have no EHR system; others have EHR, but haven’t yet integrated it with the IRIS Registry. Here are some tips for such practices.

    Five Steps to Take Today

    Step 1: Use the QPP Participation Status Lookup tool (see below) to see whether you are required to participate in MIPS

    Step 2: While checking your participation status, confirm whether CMS has classified your practice as small or large.

    Step 3: Review either the Small Practice Roadmap or the Large Practice Roadmap.

    Step 4: If you are not already signed up to use the IRIS Registry for manual reporting, do so by Oct. 31.

    Step 5: Take advantage of the Academy and AAOE’s full range of MIPS resources, and schedule time for some MIPS events at AAO 2019.

    Must You Take Part in MIPS?

    First, find out whether you are required to participate in MIPS in 2019. Clinicians may be exempt from the MIPS program if an exclusion—such as the low-volume exclusion—applies to them. Check the MIPS participation status for each clinician in your practice. Make sure you have each clinician’s 10-digit National Provider Identifier (NPI) handy and visit the QPP Participation Status Lookup tool

    MIPS tip. If a clinician is in more than one practice, when you use the QPP Participation Status Lookup tool, you should scroll down to find his or her status at each practice.

    CMS uses two time segments to determine 2019 MIPS participation status. CMS first looks at data from Oct. 1, 2017, to Sept. 30, 2018, (with a 30-day claims run out) and later reviews data from Oct. 1, 2018, to Sept. 30, 2019. At time of press, the QPP Participation Status Lookup tool shows who is excluded from having to participate in MIPS based on that first time segment; in November, additional clinicians may be excluded based on data from the second time segment.

    What if you are not required to participate in MIPS? If you are an IRIS Registry participant and you learn that you are not required to report, ask your practice administrator to contact to notify the IRIS Registry that you will not be reporting for 2019 MIPS because you are not eligible. Be sure to include your IRIS Registry practice ID and practice name in the subject line of the email, and include the clinician’s NPI. Similarly, if you are not required to report but wish to opt in to the program, email

    What if your practice is in an accountable care organization (ACO)? You could just rely on the ACO’s MIPS reporting, but many practices that are in ACOs also choose to do their own MIPS reporting. Joyce Hogue, CPC, OCS, Quality Analyst at Wheaton Eye Clinic in Wheaton, Illinois, has taken this approach. “With a 7% penalty coming, it is important to have a safety net,” she said. Reporting separately can help your practice avoid automatic penalties in case the ACO fails in its reporting.

    Small or Large Practice?

    Has CMS designated your practice size as small or large? You can find out using the QPP Participation Status Lookup Tool. This is important because MIPS reporting requirements vary depending on practice size. For example, clinicians in small practices don’t have to do as many improvement activities. They also can apply for a small practice significant hardship exception to the EHR-based promoting interoperability (PI) performance category. (For an example of how these small practice–accommodations can help ophthalmologists avoid the MIPS penalty, see "Help! I am a Solo Practitioner With No EHR.")

    What’s New in 2019?

    You must do more to avoid a penalty. During the 2019 performance year, practices that want to avoid the penalty must complete quality reporting in addition to improvement activity attestations. Previously, attesting for the improvement activity performance category was sufficient.

    Important change to IRIS Registry submission. Complete submissions to CMS by using the “Submit” button in the IRIS Registry MIPS portal.

    What else is new? Read a brief summary of what changed in 2019, or take a deeper dive into how the regulations have changed.

    Which Quality Measures Should You Report?

    Each year, Ms. Turkish reviews the quality measures as soon as the Academy posts them online on its Medicare quality measure pages. She looks for any changes to the measures and then makes her selections.

    You also can go to Table 8 of EyeNet’s MIPS manual to see which measures are subject to scoring limitations—some measures may be subject to a 7-point cap on achievement points, scoring for some measures may “stall” before the 10th decile, and some measures may lack a benchmark. (If reporting via IRIS Registry–EHR integration, use Table 7; if reporting via Medicare claims, use Table 9.)

    Practices must report on six quality measures, and at least one of these should be an outcome measure. If no outcome measure is available, you can report on another type of high-priority measure. Alternative high-priority measures include appropriate use, patient safety, efficiency, patient experience, care coordination measures, or—new for 2019—opioid-related measures.

    Which Patients to Report On?

    Practices that report quality measures via a registry must do so on patients across all payers, not just Medicare.

    Meet the data submission thresholds. To qualify for a small bonus, small practices should report on at least 60% of patients eligible for each measure across the entire calendar year, and that number can’t be less than 20 patients. Large practices must meet this 60% data-completeness criteria and the 20-patient case minimum in order to avoid a MIPS penalty.

    If you report on fewer than 100% of patients, do not cherry-pick. When you submit your MIPS quality data to CMS, you must certify that, to the best of your knowledge, your data is “true, accurate, and complete.” In August, CMS clarified that if you report on a measure for fewer than 100% of applicable patients, you should not select patients with the goal of boosting your performance rate; the agency states that such “cherry-picking” would result in data that is not “true, accurate, and complete.” 

    Small practices that aren’t going for the bonus can do less reporting to save time. If the goal is just to avoid a penalty, small practices can report each measure on a minimum of one patient; this reporting—combined with improvement activity attestation—will help these practices avoid the 7% penalty in 2021. Even if reporting on one patient, practices reporting via a registry must still provide data completeness information. Note: The Academy recommends reporting on several patients per measure even though the minimum requirement for small practices is one patient per measure.

    Keeping Track of Quality Data

    Practices reporting on at least 60% of eligible patients for each measure may need to establish a process to keep track of the quality data.

    Using a paper-based approach. Ms. Turkish creates a quality measure worksheet each year that asks for all information needed for each of the six measures that her practice reports. That worksheet is placed inside every patient chart. The technicians in her practice are trained to fill out the worksheet for each patient visit, and the worksheets are collected for a staff person to enter the data.

    Using billing software. Ms. Hogue said that her practice uses its billing software to help them gather the data they need for quality reporting. For a cataract surgery measure, for example, Ms. Hogue can run a report to get a list of patients who are eligible for that measure. She then enters data using those patient records. This process includes reviewing to see if there is any comorbid condition that would exclude the patient, and gathering the final visual acuity or complications information needed for reporting the measure.

    Start data entry ASAP. Ms. Brodoski said it is key for her practice to not save data entry for the end of the year. Instead, they input data for the quality measures as promptly as possible, patient by patient.

    Data-Completeness Totals

    What is the data-completeness requirement? As it did in 2018, CMS is requiring practices that report quality measures manually through registries to submit data-completeness totals for each quality measure reported. Even if an eligible clinician or practice reports a measure for just one patient, CMS wants to know how many patients the measure could have been reported on over the calendar year. Practices must provide the following patient counts:

    • The total number of patients eligible for each measure
    • The total number of patients excepted from each measure

    You won’t be able to submit a measure’s quality data to CMS without including those two totals.

    Contact the vendor of your billing system. Many practices will be able to readily collect the eligible patient totals from their billing systems. Contact your billing system vendor for instructions on how to run the appropriate reports.

    Get the total number of eligible patients for quality measures. First view the detailed specifications for each quality measure you report. They are posted at

    The detailed measure descriptions include the denominator criteria that indicate which patients qualify for each measure. After determining the denominator criteria, use your billing system to run a report of patients who meet those criteria. This will give you the total number of patients eligible for the measure. (Note: Don’t run these reports until after the end of the calendar year.)

    Example: Determining the total number of eligible patients for Measure 12: Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation. Run a report in your billing system for the date range “1/1/19-12/31/19.” Apply a filter for the following:

    • Diagnosis of primary open-angle glaucoma (using ICD-10 codes outlined in the measure specification)
    • Eligible CPT code billed during the 2019 calendar year (using CPT codes outlined in the measure specification)
    • Date of birth, so that only patients age 18 and older are included. If your system doesn’t have this functionality, you can print out the report using the diagnosis- and CPT code–criteria and then remove patients who do not meet the measure’s age criteria.

    Get the total number of patient exceptions for a quality measure. Some quality measures have exceptions. These are often medical- or patient-related. For example, there may be a medical reason why you can’t perform an optic nerve evaluation on a POAG patient. Such exceptions should be supported by documentation. It may be difficult to run a report in your billing system to produce this total, and it may require manual counting. Note: If you have manually entered 100% of eligible patients into the IRIS Registry, the patient exceptions would already be captured, and you would already have the total number of patients excepted from the measure.

    Some quality measures do not have exceptions. Of the quality measures that can be manually reported via the IRIS Registry, the following do not have exceptions: Measures 1, 111, 117, 141, 191, 192, 236, 238, 374, 384, 385, 388, 389, 402, and the manually reported measures developed by the IRIS Registry (IRIS1, IRIS2, etc.).

    Gathering data manually. If you are not able to use your billing system to collect the number of patients eligible for a quality measure and/or the number excepted from the measure, you will need a manual approach for gathering this information. Because Ms. Turkish’s practice includes the quality measure worksheets in every patient chart, she is able to review the charts to calculate the eligible patients and exceptions.

    Entering Quality Data Into the IRIS Registry

    Some practices, such as Ms. Brodoski’s, have a designated staff person responsible for entering data into the IRIS Registry. Others take an all-hands-on-deck approach.

    Get step-by-step instructions on how to enter data. See the IRIS Registry user guide. If you have questions, contact

    Enter quality data at the individual-clinician level. Regardless of whether clinicians participate in the MIPS quality performance category as a group or as individuals, the data for their quality measures will be entered at the individual-clinician level. Later, when they get ready to submit their data to CMS, they would stipulate whether they are reporting quality at the group or individual level. (Note: Practices that participate in the MIPS improvement activities performance category just attest for that at the group level.)

    Improvement Activities

    To max out on the improvement activities performance category, small practices should report one high-weighted or two medium-weighted improvement activities; large practices should report two high-weighted or four medium weighted activities, or a combination of the two. There are 34 improvement activities that can be reported via the IRIS Registry. See Table 14 (PDF) for CMS’ documentation suggestions.

    MIPS Tips

    Keep staff focused on MIPS. Ms. Brodoski recommends ensuring that all staff keep on top of documentation throughout the year. She noted that this can be a challenge, so in her practice, they discuss the importance of maintaining documentation for the quality measures with staff throughout the year. “Try to get everyone on board,” she said.

    Stay up-to-date. Check two pages regularly on the Academy’s website: for important news on submitting data, and for important news on MIPS. Also check your email each Thursday for Washington Report Express.

    Should you report as an individual clinician or as part of a group? This decision may depend on each individual clinician’s MIPS eligibility. Generally, group reporting would be the preferred method of reporting for most manual reporting practices, because all eligible clinicians in the group receive credit for the single submission. Ms. Brodoski chooses this option.

    Take full advantage of the Academy’s resources. Review the nine-step to-do list for MIPS, and also schedule time for MIPS events at AAO 2019.  

    Upcoming Deadlines

    By Oct. 3, start your 90-day performance period for improvement activities and promoting interoperability measures

    By Oct. 31, make sure you are signed up to use the IRIS Registry for manual reporting.

    By Dec. 31, apply for an extreme and uncontrollable circumstances exception and/or a PI hardship exception.

    By Jan. 31, 2020, complete data entry into the IRIS Registry and sign the data release consent form. Practices should complete their data entry prior to the deadline to ensure that there is time to ask questions and review all information.


    Ms. Brodoski is with the Eye Clinic of Livonia in Livonia, Mich.; Ms. Hogue is with the Wheaton Eye Clinic in Wheaton, Ill.; and Ms. Turkish is with Lance Turkish, MD, and Associates, in New Orleans. Financial disclosures: None

    More at AAO 2019

    Attend a MIPS event at AAO 2019. There are nine events to choose from.

    Come to the IRIS Registry area of the Academy Resource Center (West, Booth 7337) to complete improvement activity attestation and sign the required data release consent form. To expedite the process, bring (1) your IRIS Registry dashboard login credentials, (2) your practice’s Tax Identification Number (TIN), and (3) your clinicians’ National Provider Identifiers (NPIs). If you do not know your practice’s login credentials, you can email before you set off for San Francisco. You will not be able to review or complete your manual reporting of quality measures there, but staff can walk you through that process.