• MIPS 2017—Quality: Select a Reporting Mechanism

    By Rebecca Hancock, Flora Lum, MD, Chris McDonagh, Cherie McNett, Jessica Peterson, MD, MPH, and Sue Vicchrilli, COT, OCS

    This Practice Perfect content is part of EyeNet’s Guide to MIPS 2017.

    Select a Reporting Mechanism

    Your choice of reporting mechanism will depend, in part, on whether or not you have an EHR system.

    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 can report quality via:

    • Your EHR vendor, or
    • IRIS Registry/EHR integration. An automated process will extract the relevant data from your records.

    Your choice of reporting mechanism will determine which 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 and non-MIPS Measures,” below). Also keep in mind that the MIPS measures that are available to you via IRIS Registry/EHR integration may depend on which EHR system you are using.

    Large practices can report via the CMS web interface. This option is only 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 mostly primary care–based, and it requires 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.

    What happens 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. Why report as a group? Suppose a practice consists of 2 comprehensive ophthalmologists, a pediatric ophthalmologist, and a neuro-ophthalmologist. The latter 2 might find it a challenge to choose 6 measures to report for themselves, but it wouldn’t be a problem for the group as a whole. When clinicians report quality as a group, all the clinicians in that group must use the same reporting mechanism for that performance category, and they must also report as a group for the other 2 performance categories: ACI and improvement activities. In general, you can report as a group without first registering as a group. The exceptions are if you plan to report via the CMS web interface or the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS survey, in which case you must register by June 30, 2017.

    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 is unsuccessful in its MIPS reporting, your quality reporting can safeguard you from the 4% Medicare payment penalty in 2019.

    MIPS and Non-MIPS Measures

    What are MIPS measures? MIPS measures are those quality measures that are published in the MIPS regulations—there are more than 200 of them, but most of them won’t be applicable to ophthalmologists.

    Which reporting mechanisms can be used for MIPS measures? Some measures can be reported by all 4 reporting mechanisms—claims, IRIS Registry/EHR integration, IRIS Registry web portal, and EHR vendor—and others by just 1 or 2. For your convenience, the Academy has compiled a list of the 31 MIPS measures that are most relevant to ophthalmology. For each measure, this list indicates which reporting mechanism can be used, offers reporting tips, and provides a link to the measure’s full description.

    What are non-MIPS measures? Non-MIPS measures are created by subspecialty societies for use with Qualified Clinical Data Registries, such as the IRIS Registry. Although they can be used in MIPS, CMS refers to them as non-MIPS measures. This is to distinguish them from the MIPS measures that were published as part of the regulations.

    Which reporting mechanisms can be used for non-MIPS measures? Ophthalmology’s non-MIPS measures can be reported via the IRIS Registry web portal.

    Don’t confuse the MIPS ophthalmology measure set with the former PQRS ophthalmology measures groups. CMS published the MIPS measures as a long list, but it also groups many of those same measures into specialty-specific measure sets, including an ophthalmology measures set. CMS created these specialty-specific measure sets so you wouldn’t have to search through the entire list of measures for those that are relevant to your practice. Ophthalmology’s measure set should not be confused with the PQRS ophthalmology measures groups—the cataracts measures group and the diabetic retinopathy measures group—neither of which was carried over to MIPS. The Academy is urging CMS to reinstate these 2 measures groups for the 2018 performance year. 

    Quality—Summary of Reporting Options

    How you choose to report quality will determine the type(s) of measures that you can submit.

    Data Submission Mechanism Medicare Claims IRIS Registry Web Portal IRIS Registry/EHR Integration EHR Vendor
    Need EHR? No No Yes Yes
    Used by Individuals Individuals or groups Individuals or groups Individuals or groups
    It involves Real-time reporting Manual data entry into web portal Automated data extraction A possible fee
    Measure types* MIPS MIPS, non-MIPS MIPS (including eCQMs) MIPS eCQMs

    *MIPS measures are those measures that are published in the MIPS regulations; non-MIPS measures are ophthalmology-specific measures that were developed by the Academy, with the help of subspecialty societies, for use with MIPS; eCQMs are electronic clinical quality measures. These were originally developed for EHR MU, then they were used as a way to satisfy PQRS reporting requirements, and now some have become MIPS measures.

    †Some measures might not be available to you (e.g., some MIPS measures can’t be reported via claims).

    Note: The CMS web interface has its own reporting requirements. The CAHPS for MIPS survey and MIPS APMs also have different reporting requirements.


    This content is excerpted from Part 2: How to Report Quality Performance (Practice Perfect, February 2017 EyeNet; published online in advance of print), which is part of EyeNet’s Guide to MIPS 2017. Part 2 includes Quality’s Place Within MIPS, Select a Reporting MechanismWhat to ReportHow You’ll Be ScoredUse the IRIS Registry, Timeline for Reporting via the IRIS Registry, and MIPS vs. PQRS.

    Also see Part 1: Know the Basics, for a 2-minute Quality Overview.

    Note: This content was based on the information available at time of press; CMS is still publishing its regulatory guidance for MIPS.

    Use These Resources
    Academy MIPS resources include:

    Sign up for the IRIS Registry, which will be the tool of choice for MIPS reporting.