This content was excerpted from EyeNet’s MIPS Manual 2017.
MIPS’ quality performance category replaces the Physician Quality Reporting System (PQRS). It contributes up to 60 points to your 2017 MIPS final score.
Your choice of reporting mechanism will depend, in part, on whether or not you have an electronic health record (EHR) system that has been approved as a certified EHR technology (CEHRT).
If your practice does not have a certified EHR, you can report quality via:
- Medicare Part B claims, or
- The IRIS Registry web portal, which—unlike claims—doesn’t involve real-time reporting and doesn’t involve entering patients multiple times.
If your practice has a certified EHR, you also have the option of reporting quality via:
- IRIS Registry/EHR integration, in which case an automated process will extract the relevant data from your records, or
Your choice of reporting mechanism will determine which quality measures you can report. You can use each of the 4 reporting mechanisms listed above to report at least some of the MIPS measures; only the IRIS Registry web portal can be used to report the ophthalmology-specific non-MIPS options (see “MIPS Versus Non-MIPS (QCDR) Measures”). If you are reporting via IRIS Registry/EHR integration, you should keep in mind that there are some EHR systems where the IRIS Registry hasn’t been able to extract the data that is needed for certain measures—so the MIPS measures that are available to you may depend on which EHR system you are using.
Large practices can report via the CMS Web Interface. This option is available to practices with 25 or more MIPS participants. It differs from the other reporting mechanisms in several ways. It has its own set of measures, which are primary care–based, and a 1-year performance period. Few ophthalmologists are likely to use this reporting mechanism.
Select just 1 reporting mechanism for quality. When reporting quality, you typically can use only 1 reporting mechanism this year. The exception is the Consumer Assessment of Health Providers and Systems (CAHPS) for MIPS survey, which can be used as a second data-submission mechanism. It is needed for certain quality measures. However, the burden of conducting this survey for 50% of applicable patients makes those measures an unappealing option.
What if you use more than 1 reporting mechanism? Suppose, for instance, you use both claims and the IRIS Registry web portal to report quality measures. CMS will not give you an aggregate score that combines claims-based submissions with IRIS Registry–based submissions. Instead, CMS will (1) assess your score for the claims-based submissions and (2) assess your score for the IRIS Registry–based submissions, and (3) assign you the higher of those 2 scores.
You do not have to use the same reporting mechanism across all performance categories. For instance, you could report quality via IRIS Registry/EHR integration and report ACI and improvement activities via your EHR vendor.
Consider reporting as a group. There are some advantages to reporting as a group see “The Pros and Cons of Group Reporting.” Group-based reporting is the default for practices that sign up for IRIS Registry/EHR integration, though they can opt to switch to reporting as individuals.
If you’re in an accountable care organization (ACO), you should still report MIPS quality measures in case your ACO’s reporting is unsuccessful. Under PQRS, a number of ACO-affiliated ophthalmologists were penalized because their ACO failed to successfully meet the PQRS requirements. Under MIPS, you should report quality measures independently of the ACO and can do so using the IRIS Registry. If the ACO is successful in its MIPS reporting, CMS will ignore the quality measures that you reported. But if your ACO fails in its MIPS reporting, your quality reporting can safeguard you from the 4% payment penalty in 2019.
Table 13: Quality—Summary of Reporting Options
How you choose to report quality will determine the quality measures that you can choose from. The Academy recommends that you use either manual reporting via the IRIS Registry (IR) web portal or automated data extraction via IR/EHR integration.
||IR Web Portal
||Individuals or groups
||Individuals or groups
||Individuals or groups
||Manual data entry
||Automated data extraction
||A possible fee
|Measures that can be reported:
||Non-MIPS* and MIPS
|Which MIPS quality measures are available?
||Download Table 15 (PDF) to see which specific MIP quality measures are available for each data submission mechanism.
* Non-MIPS quality measures—also known as QCDR measures—are ophthalmology-specific measures that were developed by the Academy, with the help of subspecialty societies, for use with MIPS; MIPS quality measures are those measures that are published in the MIPS regulations.
Note:Table 13 does not show all reporting options. The CMS Web Interface has its own reporting requirements, its own set of measures (which are mostly primary care–based), and a 1-year performance period. The CAHPS for MIPS survey and MIPS APMs also have different reporting requirements.
Next: Quality: MIPS Versus Non-MIPS (QCDR) Measures
Note: Meeting regulatory requirements is a complicated process involving continually changing rules and the application of judgment to factual situations. The Academy does not guarantee or warrant that regulators and public or private payers will agree with the Academy’s information or recommendations. The Academy shall not be liable to you or any other party to any extent whatsoever for errors in, or omissions from, any such information provided by the Academy, its employees, agents, or representatives.
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