• Practice Perfect

    From PQRS to MIPS, the IRIS Registry Is a Winning Tool for Quality Reporting

    Written By: Flora Lum, MD, Vice President of the Academy Quality and Data Science Division

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    Published online ahead of print. When reading this article, keep in mind the following deadlines for avoiding the MIPS penalty:

    Dec. 31, 2017 is the last day of the 2017 MIPS performance year. You only can report on measures and activities that were completed by this date. If reporting quality measures by claims, the service must be performed in 2017 and the claim can be submitted in early 2018, but don’t delay—your Medicare Administrative Contractor (MAC) must forward the claim to the national Medicare claims system warehouse by March 31, 2018.

    Jan. 31, 2018 is the IRIS Registry’s deadline for reporting the MIPS measures and activities that you performed in 2017 (see below) and for signing the required Data Release Consent Form. New this year: To complete the consent process, you will need to provide Academy member IDs for all the ophthalmologists in your practice.

    Note: The Academy extended the deadline for MIPS reporting and for submitting the Data Release Consent Form from Jan. 15 to Jan. 31, 2018.


    The IRIS Registry (aao.org/iris-registryhelped ophthalmology succeed at Physician Quality Reporting System (PQRS) and is now the specialty’s tool of choice for the Merit-Based Incentive Payment System (MIPS). Indeed, CMS chief Seema Verma, MPH, has said that although quality reporting is too burdensome, “one bright spot” is the IRIS Registry.

    The IRIS Registry has 2 reporting options. Use a web portal to manually report up to 3 MIPS performance cate­gories; if you integrate your electronic health record (EHR) system with the IRIS Registry, an automated process extracts data for quality reporting.

    PQRS—Widespread Success, Plus Some Lessons Learned

    In fall of 2017, practices learned wheth­er they had successfully reported PQRS for the 2016 performance year.

    What was at stake. What happens to those who failed to successfully report PQRS measures for the 2016 reporting period? In 2018, their Medicare Part B service payments will be adjusted downward. This penalty will be 2% plus an additional value-based mod­ifier penalty of 1% or 2% for smaller (no more than 10 eligible clinicians) and larger practices, respectively. Based on an average Medicare Fee Sched­ule of $270,036 for all PQRS-eligible ophthalmologists, this would translate into a penalty adjustment of $8,101 to $10,801 per ophthalmologist in 2018.

    Most ophthalmologists reported PQRS via IRIS Registry–EHR integra­tion. For the 2016 performance year, the IRIS Registry sent CMS 11,612 files for eligible clinicians and group prac­tices. Of these, 9,177 files were from practices that had integrated their EHR system with the IRIS Registry.

    Closing in on 100% success for IRIS Registry–EHR integrated practices. Through Dec. 1, 2017, the IRIS Registry had not been notified of any participat­ing practice’s fully completed EHR submission receiving the penalty adjust­ment due to unsuccessful reporting of quality measures. However, there were a handful of cases with incorrect combinations of the 2 identifiers: the National Provider Identifier (NPI), which is used to identify individual clinicians, and the Tax Identification Number (TIN), which is used to iden­tify the practice. These were corrected upon appeal to CMS.

    Most manual reporters were suc­cessful. Practices could manually re­port PQRS measures through the IRIS Registry web portal and were respon­sible for their own data entry. While it seems that most of these manual reporters were successful, several prac­tices did receive penalty notification letters for the following reasons:

    • incorrect TIN, NPI, or TIN/NPI combination
    • not reporting for a physician in the practice (in some cases the physi­cian had joined the practice partway through the year; there also were cases in which the physician worked in the practice part time or only occasionally)
    • not reporting for a TIN that is used just now and again
    • not reporting and instead relying on an Accountable Care Organization that failed PQRS

    MIPS: Beat the Jan. 31 Deadline

    First, see if you’re exempt from MIPS (https://qpp.cms.gov/participation-lookup). Next, if you signed up to use the IRIS Registry for 2017 MIPS reporting, make sure you meet the Jan. 31 deadline for (1) providing the TIN/NPI combinations, (2) submitting Data Release Consent Forms, (3) attesting to improvement activities and advancing care information measures, and, if re­porting quality measures manually via the web portal, (4) entering quality mea­sure data. (For consent form instruc­tions, see aao.org/consent-form.)

    If your practice is one in which eligible clinicians are reporting MIPS as individuals, ensure that the correct TIN/NPI combination(s) is entered for each one. Also be sure that every eligible clinician expected to remain in the practice in 2019 is included and signs a Data Release Consent Form. If your practice is group reporting, ensure that all the applicable TINs used in Medicare billing are correct in their Data Release Consent Forms.

    For more on 2017 MIPS reporting, see EyeNet’s 2017 MIPS Manual and the Academy’s MIPS hub page.

    Note: The Academy extended the deadline for MIPS reporting and for submitting the Data Release Consent Form from Jan. 15 to Jan. 31, 2018.