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    MIPS 2020—Don’t Miss These Deadlines

    By Chris McDonagh, Senior Editor, EyeNet Magazine

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    [UPDATE. After the December issue of EyeNet was printed and distributed, CMS announced that it would extend the deadline for applying for an extreme and uncontrollable hardship exception to Feb. 1, 2021.]

    If you don’t participate in the Merit-Based Incentive Payment System (MIPS) in 2020—and if you’re not excused from participating—your 2022 Medicare payments could be subject to the maximum –9% penalty. It is wise, therefore, to meet the deadlines below.

    Manual Reporting Via the IRIS Registry—Get Busy!

    By Jan. 31, 2021, those who use the IRIS Registry for MIPS reporting will need to complete the following three steps.

    Step 1: Finish manual reporting for 2020. This includes quality measures, promoting interoperability measures, and improvement activities. When manually reporting data for quality measures, you can either enter data one patient at time or enter them as a batch via a properly formatted CSV file. If you successfully integrated your elec­tronic health record (EHR) system with the IRIS Registry, your MIPS quality data are automatically extracted, but—new this year—you must select which quality measures to report.

    Include the data-completeness totals. If you are manually reporting patients for a quality measure, you must enter into the IRIS Registry the total number of patients eligible and excepted from that measure.

    If you report a quality measure on fewer than 100% of patients, do not cherry-pick. When you submit your MIPS quality data to the Centers for Medicare & Medicaid Services (CMS), you must certify that, to the best of your knowledge, your data are “true, accurate, and complete.” CMS has stated 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 as this would result in data that are not “true, accurate, and complete.” 

    Step 2: Submit a signed data-release consent form. Providers who are re­porting as individuals should sign their own consent forms; providers who are reporting as a group can be included on a single consent form, which can be signed by the administrator. All your practice’s ophthalmologists must be up to date with their 2020 Academy membership dues. You must submit a new consent form each year and can do so via the IRIS Registry dashboard. For instructions, see

    Step 3: Submit your data to CMS. Log into the IRIS Registry dashboard and complete the submission process.

    For more on the IRIS Registry, including instructions for the above three steps, visit

    Apply for Hardship Exceptions By Dec. 31, 8:00 p.m. EST

    The deadline to apply for hardship ex­ceptions is 8:00 p.m. Eastern Standard Time (EST) on Dec. 31, 2020. There are two options: 1) The extreme and uncontrollable circumstances hard­ship exception and 2) the promoting interoperability hardship exception.

    Keep documentation for six years. There is typically no requirement to in­clude supporting documentation with your application, but you should keep it on file in case of audit.

    For more on hardship exceptions, visit, and also read “MIPS 2020, the COVID-19 Pandemic, and Hardship Exceptions” (October, Practice Perfect).

    [UPDATE. After the December issue of EyeNet was printed and distributed, CMS announced that it would extend the deadline for applying for an extreme and uncontrollable hardship exception to Feb. 1, 2021.]

    Does Your EHR Have 2015-Edition Certification?

    If you are participating in MIPS using an EHR system, you should check to confirm that it is a 2015-edition Certified EHR Technology (CEHRT). If it isn’t, you’ll want to know as soon as possible so you can plan according­ly. You won’t, for example, be able to report promoting interoperability mea­sures. Also, your options for the quality performance category may be subject to some limitations.

    To check your EHR system’s cer­tification, go to When you do so, make a note of your Certified Health IT Product List (CHPL) ID#. You will need your CHPL ID# when you report promoting interoperability performance to CMS.

    For more on checking certifica­tion—including what to do if certifi­cation is pending or if the pandemic prevented you from upgrading to a 2015-edition CEHRT—see “MIPS: Does Your EHR Have 2015-Edition Certification” (Academy Notebook, November).