Skip to main content
  • Practice Perfect

    MIPS 2021—How to Boost Your Promoting Interoperability Score

    By Joy Woodke, COE, OCS, OCSR, Coding and Practice Management Executive, John Ward, Academy Manager of Customer Service, and Chris McDonagh, EyeNet Senior Editor

    Download PDF

    Promoting interoperability (PI) is the electronic health record (EHR)–based performance category of the Merit-Based Incentive Payment System (MIPS). According to CMS, the PI measures are intended to promote electronic exchange of infor­mation and to increase patient engage­ment by allowing them to access details from their health records online. 

    Many ophthalmic practices can improve their PI scores. Low perfor­mance rates on the PI measures have meant that some practices have underperformed on the PI performance category. Last year, for example, fewer than half of those reporting MIPS via the IRIS Registry ( scored more than 80% for PI. This reduced their chance of avoiding a MIPS penalty and earning a bonus. 

    Your PI performance period must start no later than Oct. 3. Your PI score will be based on how you do during a performance period of 90 consecutive days during the current calendar year.

    Best not to wait until Oct. 3! By starting your performance period earlier in the year, you will give yourself an opportunity for a do-over in case you run into problems. For example, your score for the Provide Patients Electronic Access to Their Health Information measure could be jeopardized if your patient portal goes offline for a few days.

    Make sure you understand how to perform (and document) the PI mea­sures. The Academy offers a detailed web page for each of the PI measures, including a measure description, defini­tions, and suggestions for documenting your performance. Academy and AAOE members can access these PI web pages at

    Warning: Don’t report PI twice. You’ll get a PI score of 0 if you submit conflicting data or conflicting attesta­tion on PI measures. This could happen if, for example, you report PI twice— once via the IRIS Registry and again via your EHR vendor—and submit different information each time.

    Check Performance Rates

    For many PI measures, you are scored based on your performance rate. The e-Prescribing measure, for example, can contribute up to 10 points to your PI score: If your performance rate is 100%, you would score 10 points. In calculating this point score, CMS typically rounds off to the nearest whole number—so a score of 84% would score 8 points, but a score of 86% would score 9 points. (Note: In an exception to that rounding rule for PI measures, CMS rounds up to 1 point rather than down to 0 points provided you have a numerator of at least 1.) 

    Your performance rate is based on a numerator and a denominator. For the e-Prescribing measure, the denom­inator is the number of prescriptions written during the performance period for drugs that require prescriptions; the numerator is the number of those prescriptions that were 1) generated, 2) queried for a drug formulary, and 3) transmitted electronically using a certi­fied EHR technology (CEHRT).

    You need a numerator of at least 1. For any of PI’s performance rate–based measures, you need a numerator of at least 1 to successfully report it.

    Run your PI reports ASAP. Your EHR system should be able to run a report that calculates your performance rates for PI measures. If you haven’t been running these reports throughout the year, you should do so as soon as possible to check your performance rates. If your numerator for a measure is 0, you will need time to work with your EHR vendor and your staff to determine how to attain the minimum numerator of 1.

    Provide Patients Electronic Access to Their Health Info

    One area of underperformance involves the Provide Patients Electronic Access to Their Health Information measure. In some cases, practices had been providing patients with access to their medical information online but hadn’t always been logging that, resulting in a discrepancy between their reported performance rate and their actual per­formance rate. 

    Know your numerator and denomi­nator. The denominator for the Provide Patients Electronic Access measure is the number of unique patients seen by the clinician during the PI perfor­mance period. The numerator is the number of those patients (or their patient-authorized representatives) who 1) received timely access to “view online, download, and transmit his or her health information” and 2) are able to access that information using “any application of their choice that is configured to meet the technical speci­fications of the Application Programing Interface (API)” in the practice’s CEH­RT. CMS defines “timely” as within four business days of the information being available to the clinician. 

    When a patient is provided with online access, how is that recorded in the EHR? Contact your EHR vendor and confirm how the EHR system captures the action of providing timely access. Some systems may require con­firmation in the medical record or by completing a function in the integrated practice management system.

    How do you ensure that the EHR is updated each time a patient is pro­vided with online access? Develop the workflow to successfully log that you provided this access after every patient encounter. Next, test the protocol and review your PI reports.

    What does your EHR vendor offer? You may be able to automatically offer patient access via a patient portal, but this functionality may require indi­vidual system setup. Ask your vendor whether this option is available.

    What if some patients don’t want to view their information online? Even if a patient opts out of receiving online access to personal medical information, he or she must still be included in the denominator for this measure. CMS states that you can include this patient in the numerator, provided that he or she is “provided all of the necessary in­formation to subsequently access their information, obtain access through a patient-authorized representative, or otherwise opt-back-in without further follow-up action required by the clini­cian.”

    When patients opt out, are staff taking these two steps? When patients opt out of accessing their information online, be sure that staff are trained to update the EHR to indicate that the patient 1) opted out and 2) was instructed on how to access that online information if he or she later decides to opt in. Next, double-check that your EHR system is including such patients in the measure’s denominator and, if applicable, in its numerator.

    Direct Messaging for the Referral Loop Measures

    The two Referral Loops measures involve the sending and receiving of health care summaries. This can be done in a HIPAA-compliant way via Direct messaging, which was devel­oped by the Direct Project and uses an encryption standard for exchanging health information over the internet. To use Direct messaging, both the sender and recipient must have Direct addresses, which look similar to email addresses. If your EHR is a CEHRT, the vendor must offer you access to a Direct messaging service.

    Do you have a Direct address? Prac­tices can obtain Direct addresses from a variety of sources, including CEHRT vendors, State Health Information Exchange entities, regional and local Health Information Exchange entities, and Health Information System Providers. 

    The National Plan and Provider Enu­merator System (NPPES) has started to include Direct addresses in the NPI Registry. NPPES is trying to make it easier to find the Direct addresses of other clinicians. Go to the NPI Regis­try’s search page at Once you find the clinician who you are looking for, click his or her record, and then scroll down to “Health Information Exchange.” If he or she has added a Direct address into the NPI registry, it will be listed here with “Direct Messaging Address” in the “Endpoint Type” column. However, few clinicians have added this information yet.

    How to update the NPPES directory. If you do not know your exact electron­ic end point or Direct address, contact your EHR vendor for this information. Next, go to the NPPES website ( and update your provider profile. You can add your Direct address under the “Health Information Exchange” section. CMS provided a step-by-step guide to doing this in its Medicare Learning Network Matters bulletin.1 If you already added this information, it is still worth visiting the directory to double-check that your practice’s details are up to date. By making sure that the directory has your practice’s correct Direct address(es) and electronic end point information, you can help your practice’s clinicians succeed with PI’s two Referral Loop measures.

    Contact your top referral sources. Make sure referral sources are ready to meet the requirements of the Referral Loop measures. If, like most clinicians, their Direct addresses aren’t yet listed in the NPPES NPI Registry, see if you can obtain that information directly from the practice.

    More Resources

    Bookmark these resources. To learn more about the PI perfor­mance category—including which clinicians can be excluded from it—visit and

    Use the IRIS Registry Prepara­tion Kit. Download it at

    Share tips online. AAOE mem­bers also can use the new listserv, AAOE-talk, to crowdsource MIPS solutions.

    What About PI’s New HIE Measure?

    This year, PI’s Health Information Exchange (HIE) objective gives you a choice of two measures. You either can report (or claim exclusions for) the two Referral Loop measures or you can report the new HIE Bi-Directional Exchange measure. To earn all 40 points for the new measure, you must attest “yes” to these three statements:

    • “I participate in an HIE in order to enable secure, bi-directional exchange to occur for every patient encounter, transition or referral, and record stored or maintained in the EHR during the performance period in accordance with applicable law and policy.”
    • “The HIE that I participate in is capable of exchanging information across a broad network of unaffiliated exchange partners including those using disparate EHRs, and does not engage in exclusionary behavior when determining exchange partners.”
    • “I use the functions of CEHRT to support bi-directional exchange with an HIE.”

    If you report “no” for one or more of these measures, you earn 0 points for the measure.


    1 Accessed June 18, 2021.

    Alert: CMS Changes Quality Benchmarks

    On June 11, CMS announced corrections to its benchmarks for almost all qual­ity measures. The updated benchmarks make it harder to score highly. The few flat benchmarks are the exception, as they remain unchanged. 

    Check that you’re referencing the updated benchmarks. Because of these changes, it is important to check that you are using the most current versions of the IRIS Registry Preparation Kit and User Guide (

    On June 30, CMS announced that it was suppressing two measures for claims-based reporters: Measure 1: Diabetes: Hemoglobin A1c Poor Control (>9%) and Measure 117: Diabetes: Eye Exam. The reason why? For the 2021 performance year, the specifications of those two measures had been updated: CPT codes were added to the algorithm that is used for determining whether or not a patient should be included in the numerator for these measures. However, CMS didn’t initially update its systems to reflect the changes to the measure specifications. Consequently, the performance rates for those two measures might not be accurate for claims-based reporters. The June 30 announcement only applies to those who are reporting MIPS via claims; it does not impact clinicians who are reporting MIPS via the IRIS Registry.

    Watch for future alerts. To learn about the latest MIPS developments, check your email for Washington Report Express (Thursdays) and Medicare Physician Payment Update (first Saturday of the month). AAOE members should also watch for Practice Management Express (Sundays).

    More at AAO 2021

    Visit to explore this year’s annual meeting and Subspecialty Day content.

    Get a MIPS update at this year’s Medicare Forum. Learn what’s ahead with MIPS, as well as other coding and reimbursement changes that will impact your practice in 2022.

    Learn more about EHRs. EHR-related events include the following:

    • 21st Century Cures Act: Interoperability, Information Blocking, and the ONC Health IT Certification Program Final Rule (253). Senior instructor; Jeffery Daigrepont. When: Saturday, Nov. 13, 2:00-3:15 p.m. Where: Room 203.
    • What Every Ophthalmologist Must Know About Information Technol­ogy in 2021 (Sym11). Chairs: Aaron Y. Lee, MD, and Thomas Hwang, MD. When: Saturday, Nov. 13, 2:00-3:15 p.m. Where: New Orleans Theater C.
    • Use and Misuse of Electronic Medical Records (460). Senior instruc­tor: Kirk Mack, COE, COMT, CPC. When: Sunday, Nov. 14, 3:45-5:00 p.m. Where: Room 215.
    • Artificial Intelligence: Demystification and Applications (246). Senior instructor: Sally Liu Baxter, MD. When: Sunday, Nov. 14, 3:45-5:00 p.m. Where: Room 240.
    • What to Do (and Not Do) When Migrating Your PM or EHR (616). Se­nior instructor: Randall Marsden, BBA. When: Monday, Nov. 15, 9:45-11:00 a.m. Where: Room 240.
    • The Ophthalmic Office for the Virtual World (Sym47V). Chairs: Louis R. Pasquale, MD, and James C. Tsai, MD, MBA. When: On demand. Where: Virtual.